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Digitized  by  tine  Internet  Arcinive 

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http://www.archive.org/details/manualofoperativOOstim 


A  MANUAL 


OPERATIVE  SURGERY. 


BY 

LEWIS  A.  STIMSON,  B.A.,  M.D., 

8UHOEON'  TO  THE  PRESBYTERIAN  A.VD  BKLLETUE  HOSPITALS,  PROFESSOR  OF  CLINICAL  SCRGERY 

IN   THE   MEDICAL   FACULTY   OF   THE    VMVERSITY   OF   THE    CITY    OF    XEW   YORK, 

CORRESPONDING   MEMBER   OF   THE   SOClflTf:    DE   CHIRURGIE.  OF    PARIS. 


SECON  D     EDITION. 


WITH  THREE  HUNDRED  AND  FORTY-TWO  ILLUSTRATIONS. 


THILADELPHIA: 

LEA    BROTHERS    c'c    C  O. 

1885. 


'Rl)3l 


Entered  according  to  Act  of  Congress,  in  the  year  1885,  by 

LEA    BROTHERS    &    CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C.     All  rights  reserved. 


DORNAN,  PRINTER. 


,\\ 


TO 

Professor  WILLIAM  H.  VAN  BUREN, 

IN  RECOGNITION  OF  HIS  EMINENT  MASTERY 
OF   THE    ART   AS    WELL    AS    THE   SCIENCE   OF    SURGERY, 

AND  TO 

Dr.  EDWARD  L.  KEYES, 

IN    AFFECTIONATE   REMEMBRANCE   OF  A    PERSONAL    FRIENDSHIP 
U^^NTERRUPTED  FOR  TWENTY  YEARS, 

AXD  OF  AN 

INTIMATE  ASSOCIATION  IN  MUCH  PROFESSIONAL  WORK, 


||his     Jjolume 


IS     INSCRIBED     BY 


THE  AUTHOR. 


i 


VV 


PREFACE  TO  THE  SECOND  EDITION. 


In  preparing  the  second  edition  of  this  Manual  I  have 
sought  to  indicate  the  changes  that  have  been  effected  in 
operative  methods  and  procedures  by  the  adoption  of  the 
antiseptic  method  of  treating  wounds,  and  to  describe  such 
additions  and  substitutions  as  have  been  favorably  received 
and  can  be  systematically  presented. 

The  descriptions  of  most  of  the  formal  operations  that  can 
be  rehearsed  upon  the  cadaver  remain  unchanged ;  the  chief 
alterations  and  additions  will  be  found  in  the  passages  treat- 
ing of  the  excision  of  joints  and  bones,  and  of  operations  in 
which  the  peritoneal  cavity  is  opened. 

LEWIS  A.  STIMSON. 

New  York, 
34  East  Thirty-third  Street. 

November  9,  1885. 


A^ 


PREFACE  TO  THE  FIRST  EDITION. 


In  preparing  this  Manual,  I  have  sought  to  render  it  suffi- 
ciently complete,  as  regards  both  the  number  of  operations 
described  and  the  details  of  the  descriptions,  to  meet  the 
wants  of  the  practitioner  and  of  the  student;  but,  on  the  one 
hand,  I  have  excluded  operations,  such  as  the  removal  of 
tumors,  which  can  be  described  only  in  general  terms ;  and, 
on  the  other,  I  have  tried  to  avoid  that  minuteness  of  detail 
in  non-essentials,  which  Mr.  Syme  condemned  so  vigorously 
in  the  teaching  of  the  present  day,  as  "  the  fiddle-faddle  in- 
structions, not  only  for  using,  but  even  for  holding,  the  knife, 
which  sufficiently  denote  the  poverty  of  intellect  whence  they 
proceed,  and  the  lowness  in  aspiration  to  which  they  are  ad- 
dressed." Whenever  a  knowledge  of  details,  however,  has 
seemed  essential  to  the  correct  understanding  and  performance 
of  an  operation,  I  have  not  hesitated  to  describe  them  very 
fully,  and  the  same  principle  has  governed  the  introduction 
of  descriptions  of  the  anatomical  relations  of  the  parts. 

It  goes  without  saying  that  in  the  preparation  of  a  work  of 
this  character  very  large  drafts  must  be  made  upon  the  results 
of  the  labor  of  others,  and  that  the  efforts  of  the  writer  must 
be  limited,  except  on  rare  occasions,  to  making  judicious  selec- 
tions and  judicial  comparisons.  The  list  of  methods  and 
processes  is  now  so  large  that  the  surgeon  is  more  likely  to 
advance  the  science  and  art  of  his  profession  by  elaborating 
the  materials  and  mastering  the  results  already  acquired,  than 
by  inventing  new  practices  or  reinventing  old  ones.  It  is  not 
desirable,  even  if  it  were  possible,  to  include  in  a  manual  every 
operation,  and  still  less  every  modification,  that  has  been 
suggested,   and   it   has    been   my   aim,   therefore,   either   to 


Vlll  PREFACE    TO    THE    FIRST    EDITION. 

select  for  description  in  each  case  that  method  or  process 
which  seemed  the  best,  and  then  simply  to  indicate  the  varia- 
tions which  came  well  recommended,  or  which  might  be  re- 
quired under  exceptional  circumstances,  or  else  fully  to  describe 
methods  which  differed  radically  from  each  other,  and  then  to 
indicate  their  respective  merits  and  disadvantages.  It  is  only 
proper  to  add  that  in  making  such  selections  and  comparisons, 
I  have  not  relied  solely  upon  my  own  judgment  and  experi- 
ence, but  have  fortified  them  by  reference  to  the  practice  and 
opinions  of  acknowledged  leaders  in  the  profession. 

Whenever  it  was  practicable,  I  have  gone  to  original 
sources ;  and,  while  not  making  the  question  of  priority  in 
the  invention  of  any  method  a  prominent  one,  or  spending 
much  time  in  solving  it,  I  have  placed  the  credit  where  it 
seemed  to  belong,  and  have  given  references  to  the  authority, 
so  that  any  error  can  be  readily  corrected. 

The  works  most  freely  consulted  have  been  those  by  Sedil- 
lot,  Velpeau,  Guerin,  Bell,  Dubrueil,  and  Chauvel  on  Oper- 
ative Surgery;  Oilier  and  Von  Langenbeck  upon  Excisions; 
Buck  and  Verueuil  upon  Plastic  Surgery;  Wells  on  the  Eye; 
Roosa  on  the  Ear ;  Van  Buren  and  Keyes  on  the  Urinary 
Passages;  Peaslee  on  Ovariotomy;  Thomas  on  Diseases  of 
Women ;  Tillaux  and  Richet  on  Topographical  Anatomy, 
and  the  Bulletins  de  la  Societe  de  Chirurgie. 

Many  of  the  illustrations  are  modifications  of  those  in  Du- 
brueil, Chauvel,  and  Tillaux ;  others  have  been  taken  from 
Holmes's  and  Erichsen's  Surgeries,  Wells,  Thomas,  Wood  on 
Rupture,  and  Wales  on  Bandaging ;  and  a  few  representing 
instruments  have  been  furnished  by  Tiemann  and  Reynders. 

I  have  to  thank  Dr.  Vandervoort,  the  accomplished 
librarian  of  the  New  York  Hospital,  for  many  facilities  af- 
forded me  by  him,  and  Dr.  Keyes,  Dr.  Roosa,  and  the  late 
Dr.  Peaslee,  for  their  kind  revision  of  portions  of  the  manu- 
script. 

LEWIS  A.  STIMSON. 

72  Madison  Avenue,  N.  Y.,  June  7,  1878. 


LIST  OF  ILLUSTRATIONS. 


NO.  Pi 

1.  Artery  forceps, 

2.  Square  knot, 

3.  Torsion  forceps, 

4.  Effects  of  torsion    upon    the 

coats  of  an  artery, 

5.  Acupressure, 

6.  Acupressure, 

7.  Acupressure, 

8.  Forcipressure  forceps, 

9.  Forcipressure  forceps, 

10.  Tourniquet, 

11.  Tourniquet, 

12.  Tourniquet, 

13.  Needle   holder    and    curved 

needle, 

14.  Interrupted  suture, 

15.  Continuous  suture, 

16.  Twisted  suture, 

17.  Harelip  pin, 

18.  Harelip    pin    with    movable 

point, 

19.  Buck's  pin  conductor, 

20.  Nippers  for  cutting  off  pins, 

21.  Twisted  suture,  with  rubber 

ring  in  place  of  thread, 

22.  Quilled  suture, 

23.  Serre-fine, 

24.  Continuous  or  spiral  bandage, 

25.  Reversing  the  turns, 

26.  Spica  of  the  shoulder. 

27.  Spica  of  the  groin, 

28.  Four-tailed  bandage  for  knee, 

29.  T-bandage, 

30.  Capelline  or  scalp-bandage, 

31.  Four-tailed  bandage  for  head, 

32.  Triangular  bonnet, 

33.  Suspensory  bandage, 

34.  Suspensory  apparatus  for  plas 

ter  jacket, 

35.  Tripod, 

36.  Patient  suspended  ready  for 

the  plaster, 

37.  Three  steps  of  ligature  of  an 

artery, 


iGE      NO.  PAGE 

29  '.  38.  Aneurism  needle,  54 

29  j  39.  Inner  coat  of  artery  ruptured 

30  by  ligature,  55 
40.  Ligature  of  innominate,  sub- 

30  clavian,  vertebral,  and  ax- 

31  1  illary  arteries,  58 
31    41.  Ligature  of  axillary  and  bra- 

31  chial  arteries,  64 

32  42.  Transverse     section     of    the 

32  arm,  66 

34  '  43.  Ligature  of  brachial  artery,      67 
34  I  44.  Ligature  of  radial  and  ulnar 
34  I  arteries,  68 

45.  Ligature  of  common   carotid 
38  at  place  of  election,  70 

40  46.  Ligature  of  lingual,  external 

41  carotid, occipital,  temporal, 

41  and  facial  arteries.                    73 

41    47.  Anatomical  relations  of  lin- 

I  gual  and  facial  arteries,           75 

41    48.  Ligature  of  iliac  and  femoral 

41  arteries,  79 

42  49.  Ligature  of  gluteal,  sciatic, 

and  pudic  arteries,  81 

42    50.  Ligature  of  femoral  artery,  83 

42  I  51.  Transverse  section  of  leg,  86 

42  52.  Ligature  of   anterior  tibial 

43  artery,  87 

44  53.  Ligature  of  posterior  tibial 

45  I  artery,  88 
45  j  54.  Amputations  of  fingers,  me- 

45  tacarpal  bones,  and  wrist,        96 

46  55.  Amputation  at  elbow-joint,      101 

46  56.  Disarticulation  at  the  shoul- 

47  der,  104 

47  i  57.  Disarticulation  at  the  shoul- 

48  i  der,  Spence,  106 

58.  Relationsof  the  web  and  me- 
50  '  tatarso-phalangeal  joint,       107 

50  59.  Amputations  of  toes  and  me- 

I  tatarsal  bones,  108 

51  60.  Amputation  of  great  toe,         108 
161.  Lisfranc'sand  Chopart's  am- 

53  I  putations,  HI 


LIST    OF    ILLUSTRATIONS. 


NO.  P 

62.  Chopart's,  Syme's,  and  sub- 

astragaloid    amputations 
(outer  side), 

63.  Chopart's,  Syme's,  and  sub- 

astragaloid       amputations 
(inner  side), 

64.  Amputation  at  ankle  bj'  in- 
ternal flap  (Roux). 

65.  Amputation  at  ankle  (Piro- 

goff),  outer  side, 

66.  Amputation  at  ankle  (Piro- 

goff ),  inner  side, 

67.  Amputation  of  leg, 

68.  Amputation  of  leg, 

69.  Amputation  of  leg, 

70.  Amputations     at    knee    and 

lower  third  of  thigh, 
7L.  Amputations  at  knee  and  of 
thigh, 

72.  The  exsector, 

73.  Excision  of  the  shoulder.  Oi- 

lier, 

74.  Excision  of  the  elbow-joint, 

Oilier,  Yon  Langenbeck, 

75.  Excision  of  the  elbow-joint, 

Nelaton,  Hueter, 

76.  Osteoplastic   excision   of  the 

elbow, 

77.  Excision     of    wrist,    Lister. 

Portions  of  bone  removed, 

78.  Excision     of    wrist.    Lister. 

Relation     of     incisions     to 
tendons, 

79.  Excision     of     wrist.    Lister. 

Oilier,  Von  Langenbeck, 
SO.  Excision  of  the  hip, 
8L  Subcutaneous      division      of 

neck  of  femur, 
82.  Adams's  saw  for  subcutaneous 

division  of  neck  of  femur, 
S3.  Lines  of  section   in    Sayre's 
—   •*    operation  for  anchylosis  of 

hip -joint, 

84.  Excision  of  the    knee-joint, 

cutaneous  incisions, 

85.  Excision   of  the   knee-joint, 

lines  of  section  of  bone, 

86.  Excision    of  the   knee-joint, 

lines  of  section  of  bone, 

87.  Excision  of  ankle, 

88.  Osteoplastic    excision    of  the 

foot,  Mikulicz, 

89.  Excision  of  superior  maxilla, 

90.  Excision  of  superior  maxilla, 

91.  Removal  of  naso-ptiaryngeal 

polyp.  Oilier, 

92.  Excision  of  inferior  maxilla, 

93.  Excision  of  scapula. 


112 


NO. 

94. 


95. 


113  1 

96. 

1 

97. 

118 

1 

98. 

119 : 

99. 

119 

100. 

122 

122 

101. 

124 

102. 

13U 

103. 

132 

104. 

144 

105. 

146 

106. 

151 

107. 

108. 

152 

109. 

153 

110. 

158 

HI. 

112. 

159 

113. 

162 

114. 

165 

115. 

167 

\  116. 

168 

117. 

i  118. 

169 

119. 

,  120. 

170 

121. 

122. 

172 

123! 

172 

124 

174 

125. 

177 

126. 

180 

J 

181 

127. 

185 

' 

189 

128. 

196 

1 
1 

PAGE 

Resection  of  tibia,  protec- 
tion of  periosteum  against 
saw,  201 

Excision  of  calcaneum  and 
astragalus,  205 

Trephine,  209 

Hey's  saw,  2u9 

Resection  of  supra-orbital 
and  superior  maxillary 
nerves,  212 

Cheiloplasty,  V-incision,         224 
Cheiloplasty,  oval  horizon- 
tal incision,  225 
Cheiloplasty,     Celsus's     in- 
cisions,                                      225 
Cheiloplasty,  Celsus's   flaps 

in  place,  225 

Cheiloplasty,  Dieffenbach,      226 
Cheiloplasty,     Syme-Buch- 

anan,  incisions,  226 

Cheiloplasty,     Syme-Buch- 

anan.  flaps  in  place,  226 

Cheiloplasty,  227 

Cheiloplasty,  227 

Restoration    of     lower    lip, 

Buck's  incisions,  228 

Restoration    of    lower    lip. 

Buck's  flaps  in  place,  228 

Cheiloplasty,  Malgaigne,        229 
Cheiloplasty,  Sedillot,  230 

Lengthening  of  the  mouth. 

Buck,  231 

Cheiloplasty,  upper  lip,  Se- 
dillot, incisions,  232 
Cheiloplasty,  upper  lip,  Se- 
dillot, flaps  in  place,             232 
Cheiloplasty,    upper   lip, 

Buck,  233 

Simple  single  harelip,  234 

Simple  single  harelip,  Ne- 
laton, 235 
Harelip,  single  flap,  236 
Harelip,  Giraldes,  236 
Double  harelip,  237 
Cheek  compressor,  238 
Rhinoplasty,  lateral  flaps,  240 
Rhinoplasty,    lateral     flap, 

Von  Langenbeck,  240 

Rhinoplasty,  Denonvilliers,  240 
Rhinoplasty,    Diefifenbach's 

operation,  243 

Rhinoplasty,  double  layer 
or  superposed  flaps,  Ver- 
neuil,  245 

Rhinoplasty,    Indian     me- 
thod, 247 
Rhinoplasty,  Ollier's  osteo- 
plastic method,  250 


LIST    OF    ILLUSTRATIONS. 


XI 


xo.  Page     xo 

129.  Rhinoplasty,    Italian     uie-  173. 

thod,  261     174. 

130.  Canthoplasty,  253     175. 

131.  Ectropion,  Wharton  Jone.«,     254 

132.  Ectropion,  Alphonse  Guerin,  254     176. 

133.  Ectropion,  Von    Graefe, 

Knapp,  255     177. 

134.  Ectropion,  Dieffenbach, 

Adams,  Amnion. 

135.  Ectropion,  Ricbet, 

136.  Ectropion,  Burow, 

137.  Ectropion,  Dieffenbach, 

138.  Ectropion,  modified  Indian, 

Riehet,  . 

139.  Ectropion,  Hasner  d'Artha, 

140.  Ectropion,  Denonvillier'?, 

141.  Entropion,  ligature, 

142.  Entropion,  lower  lid, 

143.  Entropion,  upper  lid, 

144.  Desmarre's  forcep.-, 

145.  Entropion,  Streatfeild, 

146.  Symblepharon, 

147.  Symblepharon,  incisions, 

148.  Symblepharon,   flaps   in 

place, 

149.  Pterygion, 

150.  Eye  speculum, 

151.  Stop   needle  and  probe  for 

cornea, 

152.  Beer's  knife, 

153.  Iridectomy  knife,  straight, 

154.  Iridectomy  knife,  bent, 

155.  Iridectomy  forceps, 

156.  Iridectomy  forceps, 

157.  Iridectomy  scissors, 

158.  Iridectomy,  incision  of  cor- 

nea, 

159.  Iridectomy,      excision       of 

iris, 

160.  Tyrrell's  hook, 

161.  Broad    needle   for   incising 

cornea, 

162.  Canula  forceps, 

163.  Iridesis, 

164.  Streatfeild's  spatula  hook, 

165.  Coaching  needle, 

166.  Depressing  cataract, 

167.  Bowman's  fine  stop  needle, 

168.  Hays's  knife  needle, 

169.  Sichel's  knife, 

170.  Von  Graefe's  cystotome  and 

curette, 

171.  Flap  extraction  of  cataract. 

Fixing  the  eye  andmaking 
the  incision, 

172.  Flap  extraction  of  cataract. 

Removal  of  lens  by  pres-  • 

sure,  284  i  210. 


256 
256 
257 

258 

258 
259 
260 
261 
262 
262 
263 
263 
264 
264 

265 
266 
267 

269 
269 
272 
272 
273 
273 
273 

273 

274 
274 

275 
275 
276 
277 
279 
279 
280 
280 
282 

282 


283 


178. 
179. 
180. 

181. 


182. 

1S3. 
184. 

185. 

186. 

187. 

188. 

189. 

190. 
191. 
19L'. 
193. 
194. 
195. 
196. 

197. 

198. 
199. 
200. 
201. 
202. 
203. 

204. 

205. 
206. 


207. 

208. 
209. 


PAGE 

Von  Graefe's  cataract  knile,  285 
Iridectomy  forceps,  285 

To  show  method  of  making 

Von  Graefe's  incision,  286 

Line   of    Von   Graefe's    in- 
cision, 286 
Diagram  of  correct  and 

faulty  sections  of  iris,  287 

Critchett's  scoop.  289 

Bowman's  scoop,  289 

Bowman's  scoop,  289 

Curette  and  mouthpiece  for 
removal  of  cataract  by 
suction,  290 

Fine-toothed    forceps    for 

strabotomy,  294 

Strabotomy  hook,  294 

Mode  of  estimating  the  de- 
gree of  squint,  296 
Double  operation    for   stra- 
bismus,                                   295 
Extirpation     of     lachrymal 

gland,  297 

Sharp-pointed     canalicalus 

director,  297 

Bowman's  probt -pointed 

canaliculus  knife,  299 

Puncture  of  the  lachrymal 

sac,  .300 

Stilling's  knife,  301 

Tonsilotome,  304 

Smith's  gag,  307 

Staphyloraphy,  308 

Staphyloraphy,  incisions,  308 
Staphyloraphy,  sutures,  308 

Staphyloraphy,  division  of 

muscles  of  soft  palate,  309 

Staphyloraphy,  passing  the 

sutures,  310 

Incisions  in  uranoplasty,  314 
Lee's  clamp  for  the  tongue,  318 
Ecraseur,  322 

Hutchinson's  gag,  322 

Bivalve  canula,  closed,  331 

Bivalve  canula,   with    tube 

in  place,  331 

Vacca  -  Berlinghieri's     oeso- 
phageal sound,  332 
Paracentesis  of  thorax,  335 
Anatomical       relations      of 
stomach  with  reference  to 
gastrotomy,  340 
Right  inguinal  enterotomy, 

Nglaton,  344 

Dupuytren's  enterotome,  348 
Suture  of  intestines,    Lem- 

bert,  351 

Sotare  of  intestines,  G€\j,     352 


Xll 


LIST    OF    ILLUSTRATIONS. 


352 


354 
358 


368 


369 


211.  Suture  of  intestines,  Bouis- 

son, 

212.  Suture  of  intestines,  B^ren- 

ger-Feraud, 

213.  Suture  of  intestines,  Jobert 

ftransverse  wound), 
214/ Hernia  knife, 

215.  Inside  view  of  internal  ab- 

dominal and  femoral  rings,  360 

216.  External     abdominal     ring 

and  abdominal  layers,  361 

217.  Variations    in    origin    and 

cour?e  of  obturator  artery,  364 

218.  Wood's  knife  and  needle  for 

radical  cure  of  hernia, 

219.  Wood's  radical  cure  of  in- 

guinal hernia;    1st  punc- 
ture, 

220.  Wood's  radical  cure  of  in- 

guinal hernia:     3d    punc- 
ture, 

221.  Radical  cure  of  large  her- 

nia ;      withdrawing     nee- 
dle, 

222.  Radical    cure   of    inguinal 

hernia  :  wires  in  place, 

223.  Radical    cure    of    inguinal 

hernia  :  vertical  section, 

224.  Pins  used  in  the  pin  opera- 

tion for  radical  cure, 

225.  Placing  the  1st  pin, 
220.  Pins  in  place, 

227.  Radical  cure  of  femoral  her- 

nia.    Wires  in  place, 

228.  Radical     cure    of      femoral 
1st  and  2d  punc- 


239. 

240. 

241. 
242. 

243. 

244. 

245. 
246. 
247. 

248. 

249. 
250. 


229. 
230. 
231. 
232. 

233. 
234. 
235. 
236. 
237. 


hernia. 

tures. 
Radical 

hernia. 
Radical 


cure    of    umbilical 

Instruments, 
cure    of    umbilical 
hernia.     Passing  1st  wire,  379 

Radical  cure  of  umbilical 
hernia.     Passing  2d  wire, 

Radical  cure  of  umbilical 
hernia.  Passing  second 
ends  of  wires, 

Radical  cure  of  umbilical 
hernia.     Wires  in  place, 

Extirpation  of  anus.  Reca- 
mier. 

Method  of  surrounding  rec- 
tum with  ligatures, 

Extirpation  of  rectum. 
Maisonueuve, 

Vidal's  operation    for  vari- 
cocele, 
238.  Vidal's  operation    for  vari- 
cocele. 


PAGE 

Vidal's  operation    for  vari- 
cocele.    The  wires,  395 

Ricord's    method    of    tying 
wires  in  varicocele,  395 

Circumcision.      1st  incision,  399 

Circumcision.     Raw  surface 
left  by  retraction. 

Circumcision.     Delavan 
1st  incision, 

Circumcision.     Delavan 
Fitting  in  the  triangle 

Circumcision.     Keyes, 

Epispadias.  Nelaton, 
Thiersch, 
Thiersch. 


Epispadias 
Epispadias, 
.step, 
Epispadias. 


399 

400 

400 
401 
403 
404 


2d 


405 
405 


37U 

251. 

252. 

253. 

371 

254. 

255. 

373 

256. 

373 

257. 

374 

258. 

374 

375 

259. 

260. 

376 

261. 

377 

262. 

263. 

379 

264. 

265. 

379 

266. 

379  267. 


i 

268. 

,380 

269. 

.380 

270. 

387 

271. 

388 

272. 

273. 

388 

274. 

394 

275. 

395 

276. 

Thiersch. 
Transverse  section. 
Hypospadias.     Theophile 

Anger,  409 

Hypospadias.     Duplay,  411 

Urethroplasty,  414 

Urethroplasty.     Xelaton,       414 
Syme's  staff,  417 

Tunnelled  staff  and  whale 

bone  guide,  417 

Clover's  crutch,  418 

Exstrophy  of  bladder.     In- 
cisions, 421 
Exstrophy  of  bladder. 

Flaps  in  place,  421 

Mercier's  elbowed  catheter,    423 
McBurney'fi        instruments 
for    y>uncture    of    bladder 
per  rectum,  425 

Thompson's  lithotrite,  427 

Keyes's  lithotrite,  427 

Scoop  lithotrite,  428 

Bigelow's  lithotrite,  429 

Bigelow's  lithotrite,  429 

Bigelow's  evacuating  appa- 
ratus, 431 
Thompson's  evacuating  ap- 
paratus, 432 
Keyes's  tube,  432 
Position  of  viscera  at  outlet 

of  pelvis,  434 

Lateral   lithotomy.     Extent 

of  incision  of  urethra,         435 
Lateral  lithotomy.    Incision 

of  neck  of  bladder,  436 

Lateral  lithotomy  staff,  437 

Lateral  lithotomy  scalpel,       437 
Lateral     lithotomy.       Bliz- 
zard's knife.  437 
Lateral    lithotomy.      Blunt 

gorget,  437 

Lateral  lithotomy,  scoop,        437 


LIST    OF    ILLUSTRATIONS. 


Xlll 


NO.  PAGE 

277.  liiitenil  lithotomy,  forcep.'',  4;^H 
27S.  Lateral  lithotomy,  forceps,  4H8 
279.  Laternl  lithi>tomy,  forceps,  l.'iS 
2.H0.  Shirted  oanula,  i:W 

2SI.   Lateral  lithotomy.   Position 

of  patient  and  incision,        l.'.'.i 

282.  Lateral    lithotomy.       Rela- 

tions of  the  incisions  to 
each  other  anil  to  the  pros- 
tate, 440 

283.  Median  lithotomy.     Staff,      442 

284.  Median    lithotomy.       Ball- 

pointed  director,  442 

285.  Median  lithotomy.    Double- 

edged  scalpel,  442 

286.  Median  lithotomy  with  rect- 

angular staff,  44.''> 

287.  Dupuytren's    double    litho- 

tome  cache,  444 

288.  Dolbeau's  dilator,  448 

289.  Guyon-Duplay  dilator,  448 

290.  Catheterization    of    the  fe- 

male; holding  the  cathe- 
ter, 450 

291.  Emmet's  buttonhole  opera- 

tion on  the  urethra,  450 

292.  Emmet's    buttonhole     scis- 

sors, 451 

293.  Sims's  speculum,  452 

294.  Curved  .scissors,  '455 

295.  Emmet's  scissors,  455 

296.  Thomas's  toothed  forceps,  455 

297.  Sponge  holder,  455 

298.  Diagram  showing  the  line  of 

union  and  direction  of  the 
sutures,  456 

299.  Appearance    at   completion 

of  the  operation,  457 

300.  Diagram  showing  area  of  de- 

nudation. The  parts  bear- 
ing corresponding  figures 
are  brought  into  apposi- 
tion by  the  sutures,  458 

301.  Emmet's    operation    for    di- 

minishing the  vaginal  out- 
let by  e.xternal  sutures,         458 
302-305.  Diagramniatic  of  method 
of    closing    complete    rup- 
ture of  perineum,  459 

306.  Ruptured    sphincter.       1st 

suture,  460 

307.  Ruptured  sphincter.  1st  and 

2d  sutures  in  place,  40i) 

308.  Half    section    through    the 

pubes,  showing  the  direc- 
tion of  the  uterus  in  lacera- 
tion through  the  sphincter 
ani.  461 


NO.  I'AOK 

309.  Vesico-vaginal  fi.«tula.   Line 

of  paring,  462 

."'10.  Vesico-vaginal  fistula. 

Drawing  the  uterus  down,  463 
;>11.  Vesico-vaginal  fi.stula. 

Needle  holder,  461 

;112.  Vesico-vaginal  fistula. 

Course  of  the  needle,  464 

3i:!.  Vesico-vaginal  fistula. 

Passing  the  needle,  464 

314.  Vesico-vaginal  fistula. 

Shield,  465 

;U5.  Vesico-vaginal  fistula. 

Fork,  465 

Ml 6.  Vesico-vaginal  fistula. 

Blunt  hook.  465 

317.  Vesico-vaginal  fistula. 

Twisting  sutures,  465 

318.  Vesico-vaginal  fistula. 

Simon's  method  of  placing 
suture?,  466 

319.  Vesico-vaginal  fistula. 

Incision  united,  467 

320.  Sims's  catheter,  467 

321.  Obliteration  of  the  vagina; 

kolpokleisis,  468 

.■]22.  Emmet's  operation   for  pro- 
cidentia, 470 

323.  Thomas's  dilating  forceps,     471 

324.  Toothed  clamp,  471 

325.  Lacerated       cervix,        side 

view,  472 

326.  Lacerated    cervix,   denuded 

surface  and  sutures,  472 

327.  Sims's    knife  for  section  of 

the  cervix,  474 

328.  Posterior  section  of  the  cer- 

vix, 474 

329.  Spencer  Wells's  trocar,  477 

330.  Spencer  Wells's  clamp,  479 

331.  Ligatures  of  the  pedicle  in- 

cluding each  other,  480 

332.  Method  of  passing  the  liga- 

ture, 480 

333.  Genu  valgum;  section  of  in- 

ternal condyle,  491 

334.  Genu  valgum  ;  internal  con- 

dyle forced  upwards,  491 

335.  Subcutaneous     ligature     of 

na;vus,  493 

336.  Ligature  of  nivjvus,  494 

337.  Ligature  of  nit'vus,  494 

338.  Ligature  of  nievus,  494 

339.  Ligatuie  of  n^evus,  495 

340.  Web  fingers,  496 

341.  Web  fingers,  497 

342.  Ingrown  toenail,  498 


CONTENTS. 


.PART 

I. 

THE  ACCE© 

SOEIEri  OF 

AN  OPERATION'. 

p.vr.E 

PAGE 

Anesthesia, 

25 

A 

ntiseptic  treatment  of  surgi 

- 

Local, 

25 

cal  wounds, 

35 

General, 

20 

S 

utures. 

39 

Administration   of   the 

an- 

Interrupted, 

40 

esthetic, 

27 

Continuous, 

40 

Rectal, 

28 

Twisted, 

40 

Arrest  of  hemorrhage, 

29 

Quilled, 

42 

Ligature, 

29 

Serre-fine, 

43 

Torsion, 

30 

Bandages, 

43 

Acupressure, 

30 

Continuous  or  spiral. 

44 

Forcipressure, 

31 

Figure-of-eight  or  spica, 

44 

Cautery, 

32 

T-bandagc, 

46 

Coagulating  application 

?,         33 

Capelline  or  scalp. 

47 

Cold, 

33 

Triangular  bonnet. 

47 

Posture, 

33 

Immovable, 

48 

Artificial  ischaemia, 

33 
PAR 

T 

Sayre's  plaster  jacket, 
II. 

49 

LIGATURE  OF  ARTERIES. 


General  directions, 

Anatomy  of  the  supra-clavicu- 
lar region, 

Ligature   of    the  innominate 
artery. 
Anatomy, 
Operation, 

Ligature    of 
artery, 
1st  portion,  left  subclavian, 
1st  portion, rightsubclavian, 
2d  portion, 
3d  portion, 
Anatomy, 


the    subclavian 


53  !  Ligature   of    the    subclavian 
i  artery — 3d  portion, 

50  '      Operation, 

j  Ligature  of  the  inferior  thy- 

57  1  roid, 

57  I      Anatomy, 

58  '      Operation, 

Ligature     of    the     vertebral 

59  artery, 
oO        Anatomy, 
Gl        Operation, 

(U    Ligature     of     the     axillary 
61  artery, 

61  j      Anatomy, 

Ligature  under  the  clavicle. 


61 

62 
62 
62 

63 
63 
63 

63 
63 
64 


XVI 


CONTENTS. 


Ligature  of   the   axillary  ar- 
tery- 
Ligature  in  the  axilla, 
Anatom}^, 
Operation, 
Ligature     of      the     brachial 
artery, 
Anatomy, 
Operation, 
Ligature  of  the  radial  artery, 
Anatomy, 

Operation,  upper  third, 
Operation,  lower  third. 
Ligature  of  the  ulnar  artery. 
Anatomy, 

Operation    at   the  junction 
of  the  upper  and  middle 
thirds. 
Operation  in  the  lower  third. 
Ligature  of  the  common  caro- 
tid. 
In  its  1st  portion, 
At  the  place  of  election. 
Ligature  of  the  external  caro- 
tid, 
Anatomy, 
Operation, 
Ligature  of  the  internal  caro- 
tid, 
Ligature  of  the  lingual  artery, 
Anatomy, 
Operation, 
Ligature  of  the  facial  artery. 
Ligature  of  the  occipital  ar- 
tery, 


64 
64 
65 

65 
65 

67 
67 
67 
68 
68 
69 
69 


69 
69 

70 
70 
70 

71 
71 
73 

74 
74 
74 

74 


76 


PAGE 

Ligature  of  the  temporal  ar- 
tery, 76 
Ligature    of    the    abdominal 

aorta,  77 
Ligature  of  the  common  iliac,  77 
Anatomy  of   the  common, 
internal,     and      external 
iliac  arteries,  77 
Operation,  78 
Ligature  of  the  internal  iliac,  80 
Ligature  of  the  external  iliac,  80 
Ligature  of  the  gluteal,  scia- 
tic, and  internal  pudic  arte- 
ries, 81 
Ligature  of   the   femoral   ar- 
tery, 82 
Anatomy,  82 
Operation,  82 
At  the  apex  of  Scarpa's 

triangle,  83 
In    the    middle    of     the 

thigh,  84 
In  Hunter's  canal,  84 
Ligature  of  the  popliteal  ar- 
tery, 85 
Ligature  of  the  anterior  tibial,  85 
Anatomy,  85 
Operation,  86 
Ligature  of  the  dorsalis  pedis,  87 
Ligature     of     the     posterior 

tibial,  87 
Guthrie's  method,  88 
Lateral  method,  88 
In  the  lower  third  and  be- 
hind the  ankle,  89 


PART  III. 


AMPUTATIONS. 


Circular  method, 

1st  time, 

2d  time, 

(6)  Alanson's  method, 
(c)  Cutaneous  sleeve, 

3d  time. 
Oval  method, 
riap  method. 

Modified  flap, 

Teale's  method. 

Long  anterior  flap. 
Amputation  of  the  fingers, 


90  Amputation  of  the  fingers — 

90  Phalanges,  94 

90  Through    the    metacarpo- 

91  phalangeal  articulation,  95 
91  Amputation  of  the  metacar- 

91  pal  bones,  96 

92  Amputation  at  the  wrist,  97 

92  Circular  method,  97 

93  Antero-posterior  flaps,  97 

93  External  lateral  flap,  98 

94  Amputation  of  the  forearm,  98 
94  Amputation  at  the  elbow-joint,  100 


CONTENTS. 


XVll 


Amputation  ut  theelbow-joint 
Anterior  flap, 

{a)   The     joint     opened 

from  behind, 
{(i)   The     joint     opened 
from  in  front, 
Lateral  flap. 
Circular, 
Amputation  of  the  arm, 
Amputation  at  the  shoulder- 
joint, 
General  considerations, 
Oval   method  (Baron  Lur- 

Double   flap   method  (Lis- 

franc), 
Spence's  method, 
Amputation  of  the  toes, 
Distal  phalanx  of  the  great 

toe. 
Disarticulation  of  the  great 

toe, 
Two  adjoining  toes, 
Amputation  of   a   metatarsal 
bone, 
Disarticulation   of   the    1st 
or  5th  metatarsal, 
Disarticulation  of  all  the  meta- 
tarsal   bones    (Lisfranc's 
amputation), 
Modifications, 
Medio-tarsal  amputation  (Cho- 

part), 
Sub-astragaloid  amputation, 
Amputation  at  the  ankle-joint 
(Syme), 
Modifications, 

A    Internal  lateral  flap 

(Roux), 
B.    Pirogoft"'s   amputa- 
tion, 
Comparison   of    the  diflerent 
methods  of   partial    and 
total   amputation  of  the 
foot, 
Amputation  of  the  leg, 
A.  Lower  third, 
1.  Circular  method, 


100 

100 

\(M\ 
101 
102 
102 

102 
102 

103 

105 
100 
107 

107 

108 
109 

109 

110 

110 
111 

111 
113 

114 

117 

118 
119 


121 
121 
121 
123 


Comparison  of  the  different 
methods  of  partial  and 
total  amputation  of  the 
foot — Amputation  of  the 
leg— 

2.  Modified  circular, 

3.  Long    anterior   flap 
(Bell), 

4.  Elliptic     posterior 
flap  (Gujon) 

B.  Middle  third, 

1.  Longanteriorcurved 
flap, 

2.  Long  anterior  rect- 
angular flap  (Teale), 

3.  Long  posterior  rect- 
angular flap  (Lee), 

4.  Single  posterior  flap, 

C.  L'pper  third. 


Circular, 
2.    Rectangular,    ante- 
rior,    and     posterior 
flaps, 
3     External  flaps    (Se- 

dillot), 
4.  Modified  flap  (Bell), 
Comparison   of    the  ditierent 
methods, 
Amputation  at  the  knee, 

A.  Disarticulation, 
Oval  method. 
Long  anterior  flap, 

B.  Amputation    through 

the  condyles, 
Anterior  flap  (Carden), 
Grilti's  modification, 
Amputation  of  the  thigh, 
Teale, 
Carden, 
Modified  flap,  in  lower  third 

(Syme), 
Long  anterior  flap, 
Amputation  at  the  hip-joint, 
Anterior  oval  method  ( Ver- 

neuil). 
Circular, 
Anterior  flap, 
Modified  oval 


123 
123 

123 

124 

124 

125 

125 
126 
126 
126 

126 

127 
127 

127 
128 
129 
129 
129 

129 
130 
131 
133 
133 
133 

133 
134 
135 

137 
138 
138 
139 


B* 


XVlll 


CONTENTS, 


PART  IV. 


EXCISION  OF  JOINTS  AND  BONES 


General  considerations, 
Major  articulations, 
Excision  of  the  shoulder-joint, 
General  considerations, 
Ollier's  method. 
Yon  Langenbeck's  method, 
By  a  transverse  incision, 
Excision  of  the  head  of  the 
scapula, 
Excision  of  the  elbow-joint, 
General  considerations, 
Central    longitudinal    inci- 
sions (v.  Langenbeck), 
Ollier's  method, 
Xelaton's  method, 
Long  radial  incision  (Hue- 

ter), 
Osteoplastic  method, 
Bilateral  incisions,  Vogt, 
Partial  excision, 
Excision  of  anchylosed  elbow, 
Ollier's  method, 
P.  Heron  Watson's  method. 
Excision  of  the  wrist, 

Bilateral  incisions  (Lister), 
Kadial  incision  (Oilier), 
Dorso-radial  incision  (Von 
Langenbeck), 
Excision  of  the  hip-joint, 
Say  re's  method, 
Ollier's  method. 
Anterior  incision, 
Anchylosis  of    the  hip-joint, 
treated   by  subcutaneous 
division  of  the  neck  of  the 
femur  (Adams), 
Division  below  the  trochan- 
ter. 
Excision, 
Establishment  of  a  false  joint 

(Sayre), 
Excision  of  the  knee-joint, 
Semilunar  incision, 
Ollier's    subperiosteal     me- 
thod, 
Transverse  incision, 
Extirpation  of  knee-joint, 
Excision  of  the  ankle-joint. 


141 
145 
145 
145 
14G 
147 
148 

148 
149 
14i» 

150 
151 
152 

152 
153 
154 
155 
155 
155 
156 
156 
159 
162 

164 
164 
104 
165 
16G 


166 

168 
168 

169 
170 
170 

171 
171 
172 
173 


PAGE 

Extirpation  of  the  ankle  joint — 
Operation  for  total  excision,  171 
Vogt's  method  by  removal 

of  the  astragalus,  175 

Osteoplastic  excision  of  foot 
(Mikulicz),  176 

Excision   of    the    bones    and 

smaller  articulations,  178 

Excision  of  the  superior  max- 
illa, 178 
General  conditions,  178 
Operation  by  one  of  the  me- 
dian incisions,  180 
Subperiosteal  excision  (Oi- 
lier), 181 
Simultaneous  excision  of  both 

superior  maxillae,  182 

Partial  and  temporary  exci- 
sions of  the  superior  max- 
illa to  facilitate  the  re- 
moval of  naso-pharyngeal 
polyps,  183 

Eesection  of  posterior  por- 
tion of  hard  palate  (N^la- 
ton),  183 

Resection  of  the  upper  por- 
tion (Von  Langenbeck),     183 
Other     methods    of    gaining 
access     to    the    pharynx 
through  the  nose,  184 

Boeckel,  184 

Oilier,  185 

Excision  of  the  inferior  maxilla,  186 
General  considerations,  186 

Pvesection    of    the    anterior 

portion  of  the  body,  188 

Resection  of  the  lateral  por- 
tion of  the  body,  188 
Resection  of  the  ramus  and 

half  the  body,  189 

Excision  of  the  entire  bone,  190 

Subperiosteal  method,  190 

Anchylosis  of  the  jaw,  191 

Excisicn  of  the  condyle,         191 

Resection  of  the  sternum,  192 

Resection  of  the  ribs,  192 

Estlander's     operation     for 

empyema,  192 


CONTENTS. 


XIX 


Excision  of  the  clavicle, 

192 

Resection  of  the  shaft  of  the 

Excision  of  the  scapula, 

194 

tibia. 

201 

Subperiosteal    method    (Oi- 

Resection of  the  fibula, 

202 

lier), 

195 

Of  its  upper  extremity, 

208 

Partial  excisions  of  the  sca- 

Of the  lower  portion. 

203 

pula, 

197 

pjxcision  of  the  entire  fibula. 

20:{ 

Resection  of  the  humerus, 

197 

Excision  of  the  bonesof  the  foot 

,  204 

Upper  portion, 

197 

Calcaneum, 

204 

Middle  portion, 

197 

A.  Holmes's  method. 

204 

Lower  portion, 

197 

B.  Subperiosteal  method 

Total  excision, 

197 

(Oilier), 

205 

Excision  of  the  ulna. 

198 

Astragalus, 

206 

Excision  of  the  radius. 

198 

Ollier's  method, 

206 

Partial  excisions  of  the  ulna 

When  dislocated. 

206 

and  radius. 

199 

When  shattered, 

206 

Excision   of    the    metacarpal 

Metatarsal  bones  and  pha- 

bones and  phalanges. 

199 

langes. 

207 

Resection  of  a  phalanx, 

199 

Trephining, 

207 

Resection  of  the  bones  of  the 

Of  the  cranium, 

207 

pelvis, 

200 

General  considerations, 

207 

Excision  of  the  coccyx, 

200 

Operation, 

209 

Resection  of  the  shaft  of  the 

Of  the  frontal  sinus. 

210 

femur, 

201 

Of  the  antrum. 

210 

PAR 

T  V. 

I\^EUROTOMY  A 

SD  TENOTOMY. 

Division     and     resection     of 

Inferior  dental  nerve — 

nerves, 

211 

B.  W^ithin  the  canal. 

217 

Supra-orbital  nerve. 

211 

C.   Before  its  entry  into  the 

Subcutaneous  division, 

212 

canal. 

217 

Excision  of  a  portion. 

212 

1.  From  within  the  mouth 

,217 

A.  Above  the  eyebrow, 

212 

2.  Through  the  cheek. 

217 

B.  Below  the  eyebrow, 

212 

Buccal  nerve, 

218 

Siipra-trochlear  nerve. 

213 

Lingual  nerve, 

218 

Superior  maxillar}'  nerve. 

213 

Moore's  method. 

218 

A.  Division  of  the  nerve  on 

Facial  nerve. 

219 

the  face. 

213 

Tenotomy, 

219 

1.  Subcutaneously, 

214 

General  considerations, 

220 

2.  Through  the  mouth. 

214 

Tendo  Achillis, 

220 

3.  By  external  excision. 

214 

Tibialis  posticus, 

220 

B.   Resection  of  the  infra- 

A. Above  the  malleolus. 

220 

orbital  portion, 

214 

B.  On  the  side  of  the  foot, 

221 

Tillaux's  method, 

214 

Tibialis  anticus, 

221 

Malgaigne's  method. 

215 

Peronei, 

221 

Liicke's  method. 

215 

Flexor  tendons  at  the  knee, 

221 

Inferior  dental  nerve, 

216 

Sterno-cleido-mastoid, 

221 

A.  At  the  mental  foramen. 

216 

Levator  palpebrie. 

221 

XX 


CONTENTS. 


PART  VI. 


PLASTIC  OPERATIONS  OX  THE  FACE. 


The    different    methods    and 

their  history, 
General  principles, 
Cheiloplasty, 

A.  Lower  lip, 

1.  Y-incision, 

2.  Oval    horizontal   inci- 
sion, 

3.  Method   of   Celsus   or 
Serres, 

4.  Dieffenhach, 

5.  Syme-Buchanan, 

6.  Buck's  method, 

7.  Square    lateral    flaps, 
Malgaigne, 

8.  Square  vertical  flaps, 

B.  Angle  of  the  mouth  (sto- 

matoplasty), 
Buck, 

C.  Upper  lip, 

1.  Vertical  flaps, 

2.  Infero-lateral  flap, 
Harelip, 

Single  harelip,  simple, 

1.  Double  flaps, 

2.  Nelaton's  method, 

3.  Single  flap, 

4.  Giraldes's  method. 
Double  harelip,  simple. 
Complicated  harelip. 

Rhinoplasty, 

1.  Superficial  defect,  not  in- 

volving  the    bones   or 
septum, 
Lateral,  oblique,  and  ver- 
tical flaps, 
Denonvillier's  method, 
Von    Langenbeck's    me- 
thod, 
Michon's  method. 
Restoration  of  columna, 

2.  Loss  of  the  septum  and 

nasal   bones,    the    skin 
remaining  entire, 
Dieffenhach 's  case, 
OUier's  osteoplastic    me- 
thod, 


Rhinoplasty — 

222 

Double   layer,   or   super- 

223 

posed  flaps. 

244 

224 

Pancoast's    subcutaneous 

224 

method, 

245 

224 

3.  Loss  of  more  or  less  of 
the  surface  and  the  sep- 

225 1 

tum, 

246 

i 

A.  Indian  method, 

246 

225 

Modifications, 

248 

226 

B.    Ollier's     osteoplastic 

226 

method. 

249 

227 

C.  Alquie's  method. 

251 

D.  Italian  method. 

251 

229 

Operations  upon  the  eyelids. 

252 

230 

Blepharoraphy, 

252 

Canthoplasty, 

253 

230 

Blepharoplasty. 

253 

231 

1.  In  ectropion. 

253 

232 

"Wharton  Jones, 

254 

232 

Alphonse  Guerin, 

254 

232 

Von  Graefe, 

255 

234 

Dieftenbach,    Adams, 

234 

and  Ammon, 

255 

234 

Richet, 

256 

235 

Knapp, 

257 

235 

Burow, 

257 

236 

Dieftenbach, 

257 

236 

Indian  method. 

257 

237 

Richet, 

259 

238 

Hasner  d'Artha, 

259 

Denonvilliers, 

260 

Ectropion  due  to  excess 

239 

of  conjunctiva, 

260 

2.   Entropion, 

260 

240 

Canthoplasty, 

260 

240 

j              Ligature, 

!              Excision  or   cauteriza- 

261 

241 

tion  of  a  fold  of  the 

241 

skin, 

261 

241 

Spasmodic     entropion, 

Von  Gi'aefe, 

261 

Excision  of  a  portion 

242 

of  the  orbicularis. 

262 

242 

Division  of  tarsal  car- 

tilage, 

262 

244 

Vertical  division. 

262 

CONTENTS.                                           xxi 

PAGE  i 

PA'iK 

•erations  upon  the  ey 

elids — 

Operations  upon  the  eyelids — 

Longitudinal 

divi- 

Ledentu's  method,           265 

sion  (Amnion  ),         2»i'J 

4.  Pterygion,                       265 

Excision  of  part 

of  tar- 

Excision,                           265 

sal  cartilage, 

263 

Ligature,                           265 

3.  Syniblepharon, 

2G3 

5.  Trichiasis,                         265 

Ligature, 

2»53 

Yon  Graefe,                      266 

Arlt's  method, 

2»i4 

Anagnoslakis,                  266 

Teale's  methi  d, 

264 

•PART  VIL 

SPECIAL  OPERATIONS. 

CHAPTER  I. 

OPERATIONS  UPON'  THE  EYE  AND  ITS  APPENDAGES. 


The  cornea, 

Removal  of  a  foreign  body, 
Puncture  of  the  cornea, 
Removal  of  a  sLaphvloma, 
The  iris, 
Iridotomy, 

Simple  incision    (Chesel- 

den,  Bowman), 
Simple  iridotomy, 

Wecker, 
Double  iridotomy, 
Wecker, 
Iridectomy, 

Antiphlogistic  iridectomy, 
Optical, 
Iridorhexis. 
Iridesis, 
Corelysis, 
Operations  undertaken  for  the 
relief  of  cataract, 
Depression  or  couching, 
Scleronyxis, 
Keratonyxis, 
Division,  Discission,  or  So- 
lution, 
Division  through  the  cor- 
nea, 
Division  through  the  scle- 
rotic (Hays), 
Extraction, 


2G7 

Operations  undertaken  for  the 

267 

relief  of  cataract — 

208 

Flap  extraction. 

282 

208 

Von  Graefe's  method, 

285 

270 

Gayett  and  Knapp, 

287 

270 

Linear  extraction. 

288 

Sco«.)p  extraction. 

289 

271 

Removal  by  suction. 
Removal  of  the  lens  in  its 

290 

271 

capsule. 

291 

Pagenstecher's  method. 

291 

271 

Secondary  cataract, 

292 

271 

Operations    for   the   relief  of 

272 

strabismus. 

293 

273 

Anatomy, 

293 

274 

Internal  rectus, 

293 

274 

Subconjunctival  method, 

295 

277 

Secondary  strabismus, 

296 

Enucleation  of  the  eyeball. 

296 

277 

Extirpation  of  the  contents 

277 

of  the  orbit, 

297 

277 

Operations  upon   the  lachry- 

279 

mal  apparatus, 
Extirpation  of  the  lachr^'- 

297 

279 

mal  gland. 
Lachrymal    sac,  duct,  and 

297 

27C 

canaliculi, 

298 

Slitting  up  the  canaliculus 

,299 

281 

Puncture  of  the  sac, 

300 

281 

Stricture  of  the  nasal  duct, 

,301 

XXll 


CONTENTS. 


CHAPTER  ir. 

OPERATIONS  UPOX  THE  EAR  AND  ITS  APPENDAGES. 

PAGE  I  PAGE 

Occlusion  of  the  external  an-  !  Incision    of    periosteum,   and 

ditorj'  canal,  301  j      trephining  of  mastoid  pro- 

Introduction  of  speculum,         301        cess,  302 

Paracentesis     of     the    drum-  Catheterization  of  the  Eusta- 

head,  302       chian  tube,  303 


CHAPTER  III. 

OPERATIONS  UPON  THE  MOUTH  AND  PHARYNX. 


Excision  of  the  tonsils, 

Staphj'loraphy, 

Uranoplasty, 

Fergusson's  osteoplastic  me- 
thod, 

Laniielongue's  method. 
Staphyloplasty, 
Excision  of  the  tongue, 

Billroth, 


30J 

Excision  of  the  tongue — 

305 

Kocher, 

320 

312 

SediUot's  method, 

321 

By  the  ecraseur, 

322 

315 

Division  of  the  frenuni. 

328 

315 

Ranula, 

824 

316 

Salivary  fistula, 

324 

317 

Deguise's  method, 

324 

320 

Van  Buren's  method, 

325 

CHAPTER  lY. 

OPERATIONS  PERFORMED  UPON  THE  NECK. 


Bronchotomy, 

Subhyoid  laryngotomy. 
Thyroid  laryngotomy, 
Crico-thyroid  laryngotomy, 
Laryngo-tracheotom}', 
De  Saint  Germain's  me- 
thod. 


325  Bronchotomv — 

326  Tracheotomy,  329 

326  By  galvano-  or   thernio- 

327  cautery,  331 

328  (Esophagotomy,  331 

Lateral  incision,  332 

328  J      Median  incision,  333 


CHAPTER  V. 

OPERATIONS  PERFORMED  UPON  THE  THORAX. 


Amputation  of  the  breast. 
Paracentesis  of  the  thorax, 


333  Paracentesis   of  the    pericar- 

334  dium,  335 


CHAPTER  VI. 

OPERATIONS  PERFORMED  UPON  THE  ABDOMINAL  WALL, 
STOMACH,  AND  INTESTINES. 

Paracentesis  of  the  abdomen,    336    Right  inguinal  enterotomy 

Gastrotomy  and  gastrostomy,    337        (Xelaton),  343 

General  considerations  and  1  Colotomy,  345 

anatomy,  337  j      Littre's  operation,  345 


Operation, 
Laparotomy, 


340 
341 


Lumbar  colotomy, 


346 


CONTENTS. 


XXlll 


Closure  of  an  artiBcial  iiniis  or 

fecal  fistula, 
Suture  of  tl)e  intestine, 
Lonj^itudinal  wounds, 
Key  bard, 
Jobert, 
Lembert, 
Gely, 
Bouis-on, 
Berenger-Feraud , 
Dubrueil, 
Transverse  wounds, 
Herniotomy,  kelotomy. 
General  directions, 

A.  Recognition  of  the  sac 
and  bowel, 

B.  Opening  of  the  sac, 

C.  Division   of  the  stric- 
ture, 

D.  Examination  and  re- 
turn of  the  bowel, 

E.  Treatment     of      the 
omentum. 

Strangulated  inguinal  her- 
nia, 
Anatomv, 
Operation, 


348: 

349 

350 

350 

351 

351 

351 

352 

353 

353 

353 

354 

355 

355 

350 

357 


859 

:]00 
3G0 
361 


Herniotomy,  kelotomy — 
Malgaignc's  method, 
Strangulated    femoral    her- 
nia. 
Strangulated  umbilical  her- 
nia. 

Strangulated  obturator  her- 
nia, 
Radical  cure  by  incision. 
Radical    cure    of    inguinal 
hernia  (Wood), 
Pin  operation  (Wood), 
Radical  cure  of  femoral  her- 
nia (Wood), 
Radical    cure  of    umbilical 

hernia  (Wood), 
Heaton's  method, 
Imperforate  anus  or  rectum. 
Prolapse  of  the  rectum. 
Recto  tomy, 

Excision  of  anus  and  part  of 
I  the  rectum, 

A.  Removal  by  the  knife, 

B.  Removal  by  ligature, 

C.  Removal    by   the   ecra- 
seur, 

:  Hemorrhoids, 


PAOF. 

303 
303 
363 


366 
366 

307 
373 

376 

378 
381 
381 
383 
384 

385 
:.85 
387 

389 
389 


CHAPTER  VII. 

OPERATIONS  UPON  THE  GENITO-URINARY  ORGANS  OF  THE  MALE. 


Castration,  390 

Hydrocele,  391 

Puncture  of  the  sac,  392 

Radical  cure,  393 

Varicocele,  393 

Excision  of  the  scrotum,  393 
Division  and  excision  of  the 

veins,  398 

Compression  b}"  pins,  394 
Compression  by  wires,  Vi- 

dal's  method,  394 
Subcutaneous  ligature,  395 
Ricord's  method,  395 
Rigaud's  method  by  expo- 
sure, 396 
Amputation  of  the  pi-nis,  396 
Operations  for  phimosis,  397 
Dorsal  incision,  397 
Circumcision,  398 
Paraphimosis,  401 
Division  of  the  frenum,  402 


Epispadias, 

IS^^laton's  method, 
Thiersch's  method, 

Hypospadias, 
Urethroplasty, 


402 
4U3 
404 
406 
408 


Th^ophile  Anger's  method,  408 
Duplay's  method, 
Urethral  fistula, 
General  considerations, 
Urethroraphy, 
Urethroplasty, 

Nelaton's  method, 

Reybard,    Dieffenbach, 
and  Delore, 

Delpech  and  Alliot, 

Sir  Astley  Cooper, 

Arlaud, 

Sedillot, 

Rigaud, 

Theophile  Anger, 

Scymanowski, 


410 
411 
411 
413 
414 
414 

415 
415 
415 
415 
416 
416 
416 
416 


XXIV 


CONTENTS, 


External  perineal   urethroto- 
my, 417 

A.  With  a  guide,  417 

B.  Without  a  guide,  419 
Perineal  incision  for  explora- 
tion of  the  bladder,  420 

Exstroph}^  of  the  bladder,  420 
Catheterization,  422 
Puncture  of  the  bladder,  424 
Above  the  pubes,  424 
Under  the  pubes,  424 
Through  the  rectum,  424 
A.     From     without  in- 
wards, 424 


Puncture  of  the  bladder — 

B.  McBurney's  method,    425 

Lithotrity,  '  426 

Litholapaxj",  431 

Lithotomy,  434 

General  considerations.  434 

Lateral  lithotomy,  437 

Median  lithotomy,  442 

Bilateral  lithotomy,  444 

Pre- rectal  lithotomy,  445 

Recto-vesical  lithotomy,  446 

Supra-pubic  lithotom}-,  446 

Perineal  lithotrity,  446 


CHAPTER  YIII. 

OPERATIONS  UPON  THE  GENITO-URINARY  ORGAXS  OF  THE  FEMALE. 


Catheterization,  449 

External  urethrotomy,  450 

Lithotomy,  451 

Urethral  lithotomy,  451 

Yesico-vaginal  lithotomy,  452 
Occlusion,  or  atresia  vaginae,  453 
Perineoraph}",  453 

Prolapse  of  the  posterior  wall 

of  the  vagina,  455 

1st  variety,  455 

2d  variety,  455 

Laceration  of    the    perineum 

and  sphincter  ani,  458 

Yesico-vaginal  fistula,  462 

Creation  of   a  vesico-vaginal 

fistula,  4G8 

Obliteration    of    the   vagina ; 

kolpokleisis,  469 

Narrowing    of    the    vagina; 

eh^troraphy,  469 

Lacerated  cervix,  472 


Posterior  section  of  the  cervix,  474 

Amputation  of  the  cervix,         475 
Bistoury  or  scissors,  475 

Ecraseur,  475 

Galvano-cautery,  475 

Ovariotomy,  476 

Incision,  476 

Search  for  adhesions,  479 

Tapping    of   the   cyst    and 

rupture  of  adhesions,  477 

Removal    of    the    sac    and 

treatment  of  the  pedicle,    479 
Cleansing  of  the  peritoneum,  481 
Closure    of    the    external 
wound, 

Yaginal  ovariotomy, 

Yaginal  hysterectomy, 

Hysterotomy   (Ca?sarean    sec- 
tion), 

Gastro-elytrotomy, 

Removal  of  Fallopian  tubes. 


481 
483 

483 

484 
485 

487 


CHAPTER  IX. 

MISCELLANEOUS    OPERATIONS. 


Splenotomy,  488 

Extirpation  of  the  kidney,  489 

Fixation  of  the  kidney,  491 

Subcutaneous  osteotomy,  491 

Genu  valgum,  491 

Shaft  of  a  long  bone,  492 


Erectile  tumors,  493 

Birth-mark,  495 

Web-fingers,  496 

Cicatricial  flexion  of  the  pha- 
langes, 497 
Ingrown  toenail,  498 


OrERATIVE   SURdERY. 

PART   I. 

THE  ACCESSORIES   OF  AN  OPERATION. 


ANESTHESIA. 

Local  ancesthesia  may  be  obtained  (1)  by  the  action  of 
cold,  or  (2)  by  the  application  of  an  agent  which  exerts 
locally  a  benumbing  effect  upon  the  nerves. 

(1)  The  low  temperature  which  produces  local  anaesthesia 
may  be  obtained  by  the  application  to  the  parts  of  a 
freezing  mixture  (ice  and  salt),  or  by  the  vaporization  of 
ether.  The  former  is  applicable  to  larger  surfaces  than 
the  latter.  A  mixture  of  cracked  ice  and  salt  is  put  in  a 
muslin  bag  and  laid  upon  the  part,  and  a  folded  compress 
or  towel  laid  over  it  to  intensify  its  action.  After  it  has 
been  in  place  two  or  three  minutes  it  should  be  removed, 
the  sensibility  of  the  skin  tested,  and  the  bag  reapplied  if 
the  desired  effect  has  not  been  produced.  When  chilled  to 
insensibility  the  skin  is  white  and  puffy. 

When  ether  is  used  for  local  anjjesthesia  it  should  be 
directed  upon  the  parts  in  a  fine  spray,  or  its  rapid  vapor- 
ization should  be  aided  by  fanning  or  blowing  upon  the 
surface.     It  is  inefficient  when  the  skin  is  very  vascular. 

(2)  Carbolic  acid  is  an  efficient  and  convenient  means  of 
producing  local  annesthesia.  A  cloth  thoroughly  wet  with 
a  three  per  cent,  solution  of  the  acid  should  be  kept  upon 
the  skin  for  fifteen  minutes,  and  then  the  undiluted  acid 
applied  with  a  brush  along  the  line  of  the  proposed  incision. 
This  is  applicable  to  the  opening  of  abscesses,  felons,  etc., 
and  to  many  minor  operations. 

3 


26         THE    ACCESSORIES    OF    AN    OPERATION. 

Hydroehlorate  of  Cocaine. — The  injection  under  the  skin 
or  into  a  nerve  of  a  few  drops  of  a  two  or  four  per  cent, 
sokition  of  the  hydroehlorate  of  cocaine  produces  a  tem- 
porary local  ani^sthesia,  sufficient  to  permit  the  painless 
performance  of  an  operation  involving  only  the  skin  or  the 
layers  immediately  underlying  it.  A  deeper  injection  into 
a  nerve  produces  anaesthesia  of  the  region  supplied  by  it. 
As  this  agent  acts  upon  the  nerve-fibres,  the  injection  should 
be  made  on  the  proximal  side  of  the  region  to  be  operated 
upon,  and  should  be  directed  toward  and  into  that  region. 

G-eneral  Ancesthesia. — The  agents  in  common  use  for 
producing  general  anaesthesia  are  (1)  ether,  (2)  chloroform, 
and  (3)  nitrous  oxide. 

The  great  merit  of  ether  is  in  safety.  Chloroform  is 
more  rapid  in  its  action  at  first,  as  usually  given,  at  least, 
less  liable  to  cause  vomiting,  less  disagreeable  in  its  after- 
efi'ects,  but  it  is  certainly  more  dangerous.  On  account  of 
its  inflammability,  ether  should  be  used  with  caution  at 
night,  and  as  its  vapor  is  heavier  than  air,  the  lights  should 
be  held  above  the  bed.  Nitrous  oxide  is  suitable  only  for 
very  short  operations.  Its  use  to  obtain  anaesthesia  for  any 
length  of  time  is  as  dangerous  as  that  of  chloroform,  per- 
haps more  so. 

Ether  endangers  life  through  suffocation,  which  may  be 
the  result  of  paralysis  of  the  respiratory  muscles,  or  of 
obstruction  of  the  air-passages  by  the  tongue,  or  by  a  foreign 
body,  such  as  vomited  matter.  Chloroform  kills  by  exerting  a 
special  influence  upon  the  ganglionic  nerve-centres  presiding 
over  respiration  and  circulation.  Arre£t  of  the  breathing 
and  Hvidity  of  the  surface  give  timely  notice  of  danger  from 
ether.     Chloroform  may  kill  without  a  moment's  warning. 

If  during  ani^sthetization  by  ether  the  respiratory  muscles 
cease  to  act,  artificial  respiration  should  be  kept  up,  and 
stimulants  administered;  but  the  patient  should  be  kept 
quiet,  should  not  be  whipped  oi-  excited  to  muscular  action. 
The  danger  comes  from  the  weakness  of  his  muscles,  and 
they  must  not  be  called  upon  for  any  extra  exertion.  If, 
as  is  much  more  common,  the  diaphragm  acts,  but  the  air- 
passages  are  obstructed,  and  the  fiice  becomes  livid,  the 
obstruction  must  be  removed,  and  the  breathing  will  then 


ANAESTHESIA.  27 

take  care  of  itself.  If  tlie  ohstriietion  is  due  to  the  presence 
nf  a  foreign  body  in  tlie  glottis  or  trachea  (false  teeth,  vomited 
matter),  the  sh(»uldei*s  and  head  must  be  lowered,  and  the 
hips  raised.  It  may  become  necessary  to  resort  to  trache- 
otomy. If  the  oltstruction  is  due  to  the  fallinir  back  of  the 
tongue  in  c(»nse«|uence  of  the  relaxation  of  the  muscles  of 
the  pharynx  and  floor  of  the  mouth,  a  stout  piece  of  wood 
should  be  put  between  the  patient's  teeth  and  his  tongue 
drawn  forward.  The  most  [)rompt  and  efficient  Avay  of  doing 
this  is  for  the  operator  to  hook  the  terminal  joint  of  his  fore- 
finger behind  the  root  of  the  tongue  an<l  draw  it  forward,  or 
the  fingers  should  I >e  pressed  upward  an*]  inward  from  below 
the  angles  of  the  jaw. 

When  operating  upon  the  mouth  and  nasal  passages, 
hemorrhage  may  interfere  seriously  with  respiration  and 
aniesthetization:  By  placing  the  patient  on  his  back,  and 
allowing  his  head  to  hang  down  over  the  end  of  the  operating 
table,  the  blood  will  be  made  to  flow  awav  throucrh  the  nos- 
trils,  and  the  larynx  will  remain  clear. 

During  the  inhalation  of  chloroform,  death  may  occur 
either  suddenly  by  syncope,  or  more  slowly  with  signs  of 
cerebral  congestion  and  arrest  of  hi^matosis.  In  the  first 
case  the  heart  stops,  the  patient  becomes  pale,  the  respira- 
tion superficial ;  the  other  usually  happens  after  conscious- 
ness has  returned,  the  face  suddenly  becomes  livid,  the 
patient  loses  consciousness  again,  and  dies  within  half  an 
hour.  In  the  first  variety,  death  can  generally  be  averted 
by  lowering  the  head,  slapping  the  breast  and  fiice  with  wet 
towels,  and  applying  the  galvanic  or  faradic  current.  When 
the  galvanie  current  is  nse<l.  the  negative  pole  may  be  placed 
in  the  mouth,  and  the  positive  pole  at  the  anus.  The  faradic 
current  should  be  applied  only  over  the  chest ;  its  application 
to  the  phrenic  or  pneumogastric  nerves  in  the  neck  is  danger- 
ous.    In  the  second  variety  death  is  apparently  inevitable. 

Bv  the  inhalati(^n  of  nitrite  of  amvl  imnendinij  death  mav 
sometimes  be  averted. 

Adniinistratinn  of  the  An'istlidic. — Chloroform  should  be 
given  upon  a  compress  folded  twice  longitudinally  and  once 
transversely,  so  as  to  be  about  six  inches  stjuare.  The  upper 
fold  is  then  thrown  back,  a  drachm  of  chloroform  poured 


28         THE    ACCESSORIES    OF    AN    OPERATION. 

upon  the  lower  one,  and  the  upper  one  replaced  to  prevent 
evaporation  from  that  side.  The  compress  is  then  held  be- 
fore the  mouth  and  nostrils  of  the  patient,  and  whenever 
necessary  the  upper  fold  is  thrown  back,  and  additional 
chloroform  poured  upon  the  lower  one.  No  special  instru- 
ment is  needed  to  prevent  the  administration  of  too  much  at 
a  time.  It  has  been  demonstrated  that  the  amount  of  the 
vapor  of  chlorofonii  in  the  air  never  exceeds  4J  per  cent. 

To  give  ether  successfully  three  points  must  be  provided 
for:  the  evaporating  surface  must  be  large,  the  air  inspired 
by  the  patient  must  pass  across  it,  the  supply  of  ether  must 
be  abundant  so  as  not  to  require  frequent  renewal.  The 
ordinary  cone,  with  certain  modifications,  meets  these  wants 
very  w^ell.  Three  or  four  thicknesses  of  stout  brown  paper, 
or  ten  of  newspaper,  measuring  twelve  by  fifteen  inches, 
should  be  covered  with  a  thick  towel  well  pinned  on,  and 
rolled  into  the  form  of  a  cone,  a  foot  long  and  five  inches  in 
diameter,  and  fastened  with  long  pins.  A  hole  should  be 
left  at  the  apex  of  the  cone  large  enough  to  admit  the  little 
finger,  and  the  corners  at  the  base  should  be  turned  back. 
If  the  towel  is  thick  it  will  hold  all  the  ether  that  is  needed, 
and  if  the  base  is  pressed  closely  against  the  chin,  cheeks, 
and  nose,  all  the  air  breathed  by  the  patient  will  have  to 
enter  by  the  hole  left  at  the  apex,  and  pass  across  the  large 
evaporating  surface  of  the  inside  of  the  cone.  If  the  cone 
is  held  at  first  at  a  short  distance  from  the  mouth  and  then 
brought  gradually  nearer,  complete  anaesthesia  may  often  be 
obtained  in  two  or  three  minutes  without  having  caused  any 
strangling,  or  provoked  any  resistance. 

Rectal  Etherization. — It  was  shown  by  Molliere,  in  1884, 
that  general  anaesthesia  could  be  readily  obtained  by  the  ad- 
ministration of  ether  by  the  rectum.  The  method  was  at 
once  widely  tried  but  has  been  abandoned,  except  in  special 
cases,  for  it  was  found  to  be  more  dangerous  than  the  method 
by  inhalation.  The  dangers  are  that  the  anf^sthetization 
may  unwittingly  be  made  too  profound  and  prolonged,  and 
that  the  contact  of  the  ether  with  the  intestinal  mucous 
membrane  may  cause  a  bloody  diarrhoea. 

The  ether  is  placed  in  a  bottle  provided  Avith  a  tightly 
fitting  cork  through  which  passes  a  rubber  tube.     The  free 


ARREST    OF    HEMORRHAGE. 


29 


en«l  of  the  tiil»c  is  insiTtod  in   the  rectum,  ami  the  bottle 
j)hice«l  in  warm  water. 

The  precautions  to  be  observed  are  that  the  water  should 
not  be  warmer  than  100°  Fahr.,  and  that  as  soon  as  anaes- 
thesia is  obtained  the  tube  should  be  withdrawn  from  the 
rectum,  to  be  reapplied  if  necessary.  The  tube  should  be 
large,  and  should  extend  downward  from  the  anus  to  the 
bottle  without  loops  or  coils  in  which  the  ether  might 
condense. 

ARREST    OF    HEMORRHAGE. 

Hemorrhage  is  arrested:  (1)  by  ligature;  (2)  by  torsion; 
(8)  by  temporary  mechanical  occlusion,  without  injury  to  the 
walls  of  the  vessels  (acupressure,  forcipressure) ;  (4)  actual 
cautery  ;  (5)  coagulating  applications;  (6)  cold  or  heat. 

Ligature. — The  ordinary  ligature  is  made  of  waxed  silk 
or  catgut,  and  is  applied  by  seizing  the  end  of  the  vessel 

Fig.  1. 


Art«T>-  f«»!x>*iiBJ. 


with  artery  forceps  (Fig.   1),  drawing   it  slightly  fi'om  its 
sheath,  and  then  throwing  the  ligature  about  it.     The  knot 


Fig.  2. 


S<iuare  knot. 

.should  be  a  simple  **  square  knot"  (Fig.  2),  and  should  be 
drawn  tight.  Instead  of  forceps,  a  tenaculum  may  be  used, 
and  the  ligature  thrown  over  its  point.  The  great  objection 
to  the  silk  ligature,  unless  antiseptic,  is  that  it  acts  as  a 
foreign  body  in  the  wound,  and  must  be  thrown  off  by  sup- 

3* 


30 


THE    ACCESSORIES    OF    AN    OPERATION. 


puration.  The  catgut  ligature  is  free  from  this  objection ; 
it  dissolves  promptly  without  causing  sujipuration,  and  yet 
it  occludes  the  vessel  for  a  sufficient  length  of  time. 

Torsion. — The  end  of  the  artery  should  be  seized  with  a 
pair  of  self-fastening  flat-bladed   forceps  (Fig.   3),  slightly 

Fig.  3. 


Torsion  forceps. 


drawn  from  its  sheath,  and  twisted  until  it  parts.     Care  must 
be  taken  not  to  include  much  of  the  adjoining  tissues  in  the 

Fig.  4. 


Effect  of  toreiou  upon  the  coats  of  au  artery. 

grasp  of  the  forceps.  Torsion  has  been  successfully  applied 
even  to  the  femoral  artery,  but  occasionalh"  severe  secondary 
hemorrhage  has  followed.  Its  advantage  over  the  silk  liga- 
ture  is  that  it  leaves  no  foreign  body  in  the  wound,  but,  in 
this  respect,  it  is  not  superior  to  catgut.  It  is  not  in  general 
use  except  for  small  vessels. 

Acupressure^  Forcipressure. — The  principle  of  acupres- 
sure is  to  compress  the  vessel  (Figs.  5,  6,  7)  at  a  short  dis- 
tance from  its  cut  end  against  the  neighboring  tissues  by 
means  of  a  pin  passed  under  it.  The  pressure  may  be  in- 
creased by  giving  the  pin  different  directions  at  different 


ARREST    OF    HEMORRHAGE. 


31 


ports  of  its  course,  so  as  to  twist  the  tissues,  or  by  passing'  u 
loop  of  annealed  wire  over  it.     The  pins  should  be  with- 


FiG.  5. 


-==^ 


drawn  at  the  end  of  forty-eight  hours.  The  device  of  leaving 
a  tenaculum  in  place  for  a  day  or  two,  when  a  ligature  will 
not  hold  after  its  withdrawal,  is  a  kind  of  acupressure. 


Fig.  6. 


Fig.  7. 


Forcipressure  consists  in  grasping  the  bleeding  point  with 
a  pair  of  self-fastening  forceps,  and  leaving  them  in  place, 
without  using  a  ligature.     This  method  is  commonly  used 


32 


THE    ACCESSORIES    OF    AN    OPERATION. 


for  the  prompt  arrest  of  bleeding  during  an  operation.  When 
the  knife  is  hud  aside  the  forceps  are  taken  up  in  turn  and 
remoA^ed  after  a  ligature  has  been  thrown  about  the  tissues 
grasped  by  them. 


Fig.  8. 


Self-holding  hjemostatic  forceps. 


Fig.  9. 


Sell-lioMing  haemostatic  forceps  ;  curved. 


Actual  Cautery. — This  is  a  very  efficient  and  prompt 
haemostatic ;  it  may  be  applied  as  well  to  oozing  surfaces  as 
to  bleeding  points  which  cannot  be  tied. 


ARTIFICIAL    ISCHiEMlA.  33 

Of  Codguhitinfi  Apj^Ucatiojis  it  is  necessary  to  mention 
only  tlie  li({U()r  ferri  subsiilpliatis.  It  may  be  af)plie(l  di- 
rectly to  the  raw  surfaces,  or  upon  a  tampon  of  charpie,  or 
a  sponge. 

Cold. — A  stream  of  ice  water  or  very  hot  water  will  stop 
all  oozing  very  promptly.  A  convenient  method  of  apply- 
ing heat  is  by  towels  wrung  out  in  hot  water. 

Posture. — Elevating  the  limb  will  often  stop  oozing. 


ARTIFICIAL   ISCHiEMIA. 

Loss  of  blood  during  an  operation  upon  a  limb  may  be 
prevented  by  pressure  upon  the  main  artery  on  the  proxi- 
mal side  of  the  incision.  This  pressure  may  be  made  with 
the  finger,  tourniquet,  or  elastic  cord. 

The  tourniquet  (Fig.  10)  is  composed  of  a  pad,  band,  and 
screw ;  by  turning  the  screw  the  band  may  be  tightened  at 
will.  The  principle  of  its  application  is  the  compression  of 
the  artery  against  the  underlying  bone.  A  point  should 
be  selected  in  the  course  of  the  artery  where  such  com- 
pression can  be  made ;  a  roller  bandage,  an  inch  in  diameter, 
placed  over  the  vessel,  and  parallel  to  its  course,  the  tourni- 
quet then  applied  as  shown  in  Figs.  11  and  12,  and  the  screw 
tightened.  Some  surgeons  prefer  to  place  the  pad  of  the 
tourniquet  upon  the  roller  bandage  itself,  and  not  on  one 
side  as  shown  in  the  figure.  The  buckle  on  the  band  should 
always  be  much  further  from  the  roller  than  is  represented 
in  the  figures. 

The  elastic  bandage,  introduced  by  Esmarch  and  known 
by  his  name,  is  intended  to  render  an  operation  entirely 
bloodless  bv  forcino-  all  the  blood  out  of  the  limb,  and  then 
preventing  the  entrance  of  a  fresh  su})ply.  By  its  aid  an 
operation  can  be  performed  upon  the  living  body  with  as 
much  ease  and  certainty  as  upon  the  cadaver,  and  it  is 
now  used  very  generally  whenever  careful  dissection  is 
necessary,  the  limits  of  a  carious  process  are  to  be  deter- 
mined, or  when  loss  of  blood  is  to  be  avoided.  The  band- 
aire  is  made  of  elastic  webbinir,  or  vulcanized  rubber,  two 
inches  broad,  and  is  applied  spirally  from  the  extremity  of 


34         THE    ACCESSORIES    OF    AN    OPERATION 

Fig.  10. 


Fig.  11. 


Fig.  12. 


TRKATMKNT    OF    SURGICAL    WOUNDS.  35 

the  limb  to  a  jioiiit  three  or  lour  iiiclies  above  tlic  |iroj)ose(l 
incision.  A  stout,  but  not  too  hard,  cord  of  India  rubber 
is  tlien  wra}>|)cd  two  or  tiirec  times  about  tlie  limb,  at  the 
upper  limit  of  the  banda<j;e,  and  secured  by  a  single  knot, 
and  the  bandajze  then  removed.  Care  should  lie  taken  not 
to  apply  the  cord  with  too  much  force.  When  the  operation 
is  ended,  the  cut  ends  of  all  the  vessels  that  can  be  detecte<l 
should  be  secured  before  the  cord  is  removed.  After  its  re- 
moval, any  that  escaped. detection  are  tied,  and  the  oozini; 
arrested  with  verv  hot  or  cold  water. 


ANTISEPTIC    TREATMENT    OF    SURGICAL  WOUNDS. 

Most  of  the  causes  of  the  mortality  of  surgical  operations 
originate  in  a  prolongation  of  tlie  process  of  repair  and  the 
attendant  su})puration.  Anything,  therefore,  which  shortens 
the  time  occupied  by  this  process,  wdiich  promotes  early 
union,  and  prevents  or  restrains  suppuration,  adds  to  the 
chances  of  the  patient's  recovery.  Among  the  jirincipal 
obstacles  to  early  union  may  be  reckoned  the  putrefaction 
of  the  secretions  from  the  cut  surfaces,  and  their  retention, 
in  large  or  small  quantities,  within  the  w^ound.  It  has  been 
demonstrated  that  juitrefaction  is  the  result  of  the  presence 
of  livino;  vegetable  oro-anisms,  which  are  alwavs  found  in 
the  air,  and  which  act  as  ferments  in  liquids  capable  of 
l)Utrefaction.  The  problem  then  is  to  rid  the  w^ound  at  the 
end  of  an  oi)eration  of  all  such  living  ferments  and  of  others 
capable  of  producing  a  s])ecific  infection,  and  to  prevent 
their  presence  and  growth  in  the  discharges  while  still  in 
contact  with  the  wound. 

The  first  method  by  which  it  was  sought  systematically  to 
accomplish  these  ends  was  the  "antiseptic  method"  intro- 
duced by  Prof.  Lister,  then  of  Edinburgh,  now  of  London. 
It  has  since  undergone  many  modifications  in  its  details,  but 
the  original  underlying  principle  is  so  firmly  established  that 
every  proposed  modification  wdl  be  unhesitatingly  judged  by 
its  degree  of  conformity  with  it. 

The  cardinal  points  are,  1st,  to  make  and  keep  the  wound 
surgically  clean  ;  2d,  to  provide  for  the  escape  of  its  secre- 
tions as  rajiidly  as  they  form  ;   3d,  to  exert  a  uniform,  mode- 


36         THE    ACCESSORIES    OF    AN    OPERATION. 

rate  pressure  upon  it,  undisturbed  by  frequent  changes  of 
dressings. 

The  first  point  is  now  generally  met  by  the  use  of  solutions 
of  corrosive  sublimate  to  wash  the  wound  and  the  adjoining 
surfaces  and  in  the  preparation  of  the  dressings;  the  second 
by  drainage  tubes  of  rubber  or  decalcified  bone,  or  by  counter- 
openings,  or  by  turning  in  the  edge  of  the  wound  at  one  or 
two  places  and  suturing  it  to  the  deeper  parts ;  the  third  by 
thick  soft  dressings  of  purified,  antiseptic  gauze,  cotton,  peat, 
peat-moss  (sphagnum),  or  sawdust. 

All  instruments  that  are  to  come  into  contact  with  the 
wound  should  be  cleaned  by  washing  and  scrubbing,  and  by 
boiling  if  they  have  previously  been  in  contact  with  infectious 
discharges,  and  should  be  kept  during-  the  operation  in  an 
antiseptic  solution ;  the  one  in  common  use  is  a  watery  solu- 
tion of  carbolic  acid  of  the  strengtli  of  1  in  20.  Corrosive 
sublimate  cannot  well  be  used  for  this  purpose  because  of  its 
injurious  action  upon  metal. 

Tivo  ivatery  solutions  of  corrosive  sublimate  are  needed,  1 
to  1000,  and  1  to  5000;  the  first  for  the  disinfection  of  the 
hands  of  tlie  surgeon,  the  skin  of  the  patient,  sponges,  drain- 
age tubes,  and  preexisting  wounds;  the  second,  1  to  5000, 
for  washing  the  wounds  made  by  the  surgeon  in  healthy, 
uninfected  tissues.  This  washing  may  be  made  continuously 
during  the  operation,  or  interruptedly,  or  only  at  its  end  be- 
fore the  wound  is  closed.  If  cutting  is  done  through  parts 
that  are  not  certainly  healthy  the  stronger  solution  should 
be  used  at  intervals.  Neither  solution  sliould  be  used  in  large 
natural  cavities,  as  the  abdomen,  or  the  mouth  or  rectum. 

Catgut  is  prepared  by  winding  it  on  large  spools  and 
placing  it  in  the  1 :  1000  solution  for  12  hours,  and  then  in 
95  per  cent,  alcohol  for  the  same  length  of  time.  It  is  then 
ready  for  use,  and  may  be  kept  indefinitely  in  the  alcohol 
without  deterioration.  The  thicker  sizes,  thus  prepared, 
will  remain  undissolved  in  the  tissues  for  more  than  a  week, 
and  can  be  safely  used  for  ligatures  en  masse,  and  even  for 
tying  the  pedicle  in  ovariotomy  or  hysterectomy.  It  can 
also  be  safely  used  for  sutures  where  the  tension  is  not  great, 
and  the  common  practice  now  is  to  use  it  as  a  continuous 
suture,  because  of  the  rapidity  with  which  the  wound  can 


TREATMENT    OF    SURGICAL    WOUNDS.  37 

til  MS  be  closed,  and  because  its  tendciicv  to  cause  acarrin£r  is 
tlu'U  less. 

Dr<tuia(/e  tuJ'cs  are  made  of  India  rubber  (tbc  red  rul)bcr 
is  tbe  best)  |  or  -^  inch  in  diameter,  with  hirge  biteral  open- 
ings at  everv  inch.  They  sliouhl  be  cut  ofV  almost  level 
with  the  skin,  and  prevented  from  slip])ing  in  or  out  bv  a 
safety-pin  transfixing  the  projecting  end  and  by  a  suture 
fixing  them  to  the  skin. 

They  should  ordinarily  be  removed  after  48  hours,  or  at 
the  first  subsequent  dressing;  if,  however,  there  is  then  a 
discharge  of  pus  or  even  of  slightly  purulent  serum,  the  re- 
moval should  not  be  complete,  but  a  short  drain  should  be 
left.  Bone  drainage  tubes,  if  properly  made,  disappear  by 
absorption  in  about  a  week. 

Dressings. — The  selected  material  (moss,  peat,  etc.)  is  pre- 
pared by  soaking  in  a  1 :  oOO  solution  of  corrosive  sublimate 
for  a  few  hours,  then  WTino-inn;  it  out  or  allowino;  the  solu- 
tion  to  drain  away,  and  then  making  it  up  with  bags  of  sub- 
linuited  iijauze  into  flat  cushions  of  various  sizes  and  about  an 
inch  thick,  which  should  be  kept  damp  until  used,  because 
when  moist  they  absorb  more  readily. 

Sublimated  gauze  or  cotton  is  made  by  soaking  the  puri- 
fied material  in  a  solution  containing  1  part  of  corrosive 
sublimate,  190  of  water,  and  10  of  glycerine,  and  then  allow- 
inor  it  to  drv. 

Schede  very  liighly  recommends  "  glasswool "  for  imme- 
diate contact  with  the  sutured  incision  (it  should  not  be  used 
on  an  open  wound)  because  of  its  softness  and  great  power 
of  absorption.  It  is  made  of  fine  spun  glass,  and  prepared 
for  use  by  soaking  in  a  1  per  cent,  solution  of  sublimate. 

The  operation  is  conducted  as  follows :  The  patient  is 
))laced  upon  a  table  slightly  raised  at  the  end  or  side  to  pro- 
mote the  escape  of  the  water  used  in  washing,  and  his  body 
protected  where  necessary  by  rubber  sheets.  Cloths  w^rung 
out  in  the  1 :  1000  sublimate  solution  are  placed  about  the  field 
of  operation,  and  the  surfiice  of  this  is  sci-ubbed  with  soap 
and  water,  shaved  if  necessary,  and  washed  with  th^  solution. 

The  instruments  are  jdaced  near  at  hand  in  shallow  trays 
containing  the  carbolic  solution,  and  a  large  flask  tilled  with 

4 


38 


THE    ACCESSORIES    OF    AN    OPERATION 


the  1 :  5<  >00  sublimate  solution  and  provided  with  a  rubber 
tube  and  stopcock,  is  conveniently  placed  at  an  elevation  of 
three  or  four  feet  above  the  bed.  Besides  holding  sponges, 
wet  towels,  and  the  strouf^  solution  for  the  hands  of  the  sur- 
geon should  be  within  reach. 

If  hemorrhage  is  not  prevented  by  a  tourniquet,  all  bleed- 
ing points  should  be  immediately  secured  with  self-fastening 
forcejts  which  are  left  in  place  until  the  cutting  is  ended  or 
until  so  many  have  been  applied  that  their  presence  becomes 
an  inconvenience.  They  are  then  taken  up  in  turn,  and  a 
catgut  ligature  thrown  about  each  point. 

If  a  tourniquet  is  used,  all  recognizable  vessels  that  have 
been  severed  are  tied,  then  the  tourniquet  removed  and  all 
bleeding  points  caught  and  tied.  Every  effort  should  be 
made  absolutely  to  arrest  all  bleeding.  Some  surgeons, 
when  usino-  Esmarch's  elastic  bandacre,  the  removal  of  which 
is  followed  by  much  troublesome  oozing,  close  the  wound 
and  complete  the  dressing  before  removing  the  cord,  trusting 
to  pressure  to  prevent  oozing.  This  method  is  not  proper 
after  amputation. 

Fig.  13. 


Halsted's  needle-holder,  with  ueedle  curved  across  the  flat. 


The  bleediiiLT  having  been  completely  arrested,  the  wound 
is  thoroucrhlv  Avashed,  drainaire  tubes  inserted  or  counter- 
openings  made,  and  the  edges  of  the  wound  brought  together 
with  sutures.  If  the  wound  is  large  and  irregular,  it  is  well 
to  fasten  its  deeper  parts  together  with  buried  catgut  sutures 
passed  by  means  of  a  curved  needle,  Fig.  13,  and  to  attach 


SUTURES.  39 

the  central  ]X)rtions  of  tlie  skin  flaps  to  the  underlyinfr  raw 
sui'faces  in  the  same  manner.  The  outer  surface  of  tlie  skin 
sh«nihl  not  be  ineludtMl  in  the  l«x>p  of  such  a  suture,  for  the 
tension  is  apt  to  cause  pain. 

If  the  skin  is  <k'licate  tlie  contact  of  muist  sublimate  dress- 
ings mav  cause  irritation,  and  it  is  well  to  use  as  a  first  laver 
a  few  tliicknesses  of  iodofomi  gauze;  over  this  are  place<l 
the  principal  dressings,  small  cushions  prepareil  as  above 
described.  «:»r  layei'S  of  gauze  or  cotton,  arrange<l  to  make 
uniform  pressure,  and  bound  on  witli  bandages  of  antiseptic 
gauze,  and  over  these  is  placed  a  large  cushion  or  a  thick 
sheet  of  prepared  cotton.  An  impervious  outside  layer,  oil 
silk  or  mackintosh,  is  no  longer  used:  it  has  proved  to  be 
better  to  have  the  discharges  (by  by  evajxjration. 

Open  icounds  are  covered  with  a  layer  of  two  to  four 
thicknesses  of  sublimate  or  iodofonn  gauze,  and  then  covere<l 
with  the  cushions  or  cotton  or.  if  hollow,  stuffed  with  crumpled 
c^auze.  When  the  dressing  is  chanored  the  laver  of  gauze  on 
the  sui-face  of  the  wound  may  usually  be  left  in  place. 


SUTURES. 

Sutures  may  be  made  of  silver,  silk,  catgut,  or  horsehair. 
If  a  suture  is  to  be  retained  for  any  length  of  time  silver  is 
the  best  material,  since  it  does  not  provoke  inflammation, 
and  has  but  a  slight  tendency  to  cut  out,  unless  tension  is 
caused  by  inflammatory  swelling.  Silk  answers  equally  well 
if  it  is  to  be  retained  for  only  a  short  time,  and  usually  it  can 
be  removed  with  less  pain  and  disturbance  of  the  parts.  If 
carbolized,  and  used  in  connection  with  the  antiseptic  dress- 
ing, it  is  as  unirritating  as  silver.  Catgut  is  unirritating 
and,  if  properly  made  and  not  too  old,  its  buried  portion 
will  melt  away  in  a  few  days.  Horsehair  is  prepared  by 
soaking  in  oil.  which  makes  it  pliable  and  diminishes  its 
brittleness;  it  is  useful  when  there  is  but  little  strain  upon 
the  parts,  and  when  it  is  desirable  that  no  marks  shouM  be 
left  by  the  sutures. 

Sutures  can  hardlv  be  retained  too  lono^  a  time  if  an  ade- 


40 


THE    ACCESSORIES    OF    AN    OPERATION. 


qiiate  exit  has  been  provided  from  the  first  for  the  discharges ; 
they  keep  the  parts  in  easy  contact  and  obviate  the  necessity 
for  the  frequent  reapplication  of  strips  of  adhesive  plaster. 
A  serious  objection  to  the  interrupted  suture  in  some  cases 
is  the  scar  which  it  leaves,  even  Avhen  it  has  not  been  allowed 
to  cut  out.  The  pressure  of  its  loop  upon  the  included 
tissue  is  a  traumatism  which  is  followed  by  the  production  of 
inodular  tissue  and  a  raised  cicatrix  in  its  line.  The  continu- 
ous, twisted,  and  quilled  sutures  are  free  from  this  objection. 

1.   The  different  kinds  of  suture  are : 

1.  The  interrupted  (Fig.  1-4),  in  which  each  stitch  is  tied 
as  it  is  made,  and  the  knot  left  on  the  least  dependent  side. 

Fig.  14. 


Interrupted  suture. 


If  silver  is  used  the  edges  of  the  wound  are  brought  into 
contact  by  drawing  upon  the  ends  of  the  wire,  and  the  stitch 
fixed  by  crossing  them  over  the  incision,  and  giving  each  a 
half  turn  about  the  other,  and  then  twisting  them  two  or 
three  times.  Or  the  ends  may  be  engaged  in  a  split  shot 
and  fixed  by  compressing  it  upon  them,  or  brought  through 
buttons  or  holes  in  a  metal  plate,  and  then  fastened  together. 

2.  The  continuous  suture  (Fig.  15),  which  is  passed  in 
the  same  manner  as  the  interrupted,  but  the  stitches  are  not 
cut  apart  and  tied.  It  is  conveniently  fastened  at  the  last 
by  drawing  it  double  through  the  last  stitch  and  using  the 
free  end  to  make  a  knot  with  the  double  part  attached  to  the 
needle. 

3.  The  twisted  suture  (Fig.  KJ).  made  by  transfixing  the 


SUTURES 


41 


li|»s  of  tlie  incision  witli  ;i  ]>in,  alioiit  tlie  two  ends  of  which 
a  stout  thread  is  then  twisted.  The  pins  may  have  niova))Ie 
l)oints,  as  shown  in  Figs.  17  and  18,  or  stout  '\sol id-headed" 


Fig.  15. 


Fio.  k;. 


C'ontiiiuou.s  suture. 


Twirtti'il  suture 


Fig    17. 


O 


Ilarulip  ijin. 

Fig.  18. 


Harelip  piu  with  muvable  point. 


pins  may  be  used  and  passed  either  in  the  usual  manner,  or 
with   the   aid  of  Buck's   pin-conductor  (Fig.  19).     Their 


Fig.  19. 


Duck's  pill  conductor. 

4* 


42 


THE    ACCESSORIES    OF    AN    OPERATION. 


points  should  he  cut  off"  Avith  nippers  (Fig.  -0),  after  they 
have  been  inserted,  and  the  skin  protected  at  each  end  by  a 


Fig.  20. 


Nippers  for  cutting  off  pins. 


strip  of  adhesive  plaster.     Instead  of  thread,  a  rubber  ring 
is  sometimes  used  (Fig.  21). 


Fig.  21. 


Fig  22. 


Twisted  suture.    A  rubber  riug   is  used  in  the 
place  of  thread. 

4.  The  quilled  or  button  su- 
ture (Fig.  22),  in  which  the  wire 
or  thread  is  passed'double  and 
tied  over  pieces  of  gum  catheter 

Fig.  28. 


/ 


Serre-fine. 


Quilled  suture 


or  ivory  rods  r)r  buttons.  This  is  employed  when  the  tension 
is  great,  or  when  the  deep  parts  tend  to  drag  asunder,  and 
allow  the  secretions  to  collect.  The  points  of  entry  and 
emergence  of  the  sutures  should  be  at  a  considerable  distance 
from  the  incision. 


BANDAGES. 


43 


Fio.  24. 


The  serre-Hne  (Fiir.  28)  mav  be  used  wlien  tlie  tension  is 
slifrht,  and  when  tlie  edores  of  the  incision  will  not  needtoI)e 
held  together  for  more  than  twenty- 
four  hours.  It  is  a  small  self-retain- 
inir  force} ><.  with  toothed  blades,  and 
is  made  of  silver  wire.  The  blades  ir 
are  separated  by  pressing  upon  the 
sides,  and  spring  together  when 
the  pressure  is  removed. . 

For  other  kinds  of  sutures  see 
Wounds  of  the  Int^'stines. 


BANDAGES. 

Ordinary  roller  bandages  should 
be  made  of  strips  of  strong  un- 
bleached muslin  from  2}  to  3J 
inches  in  width  and  about  four 
yards  long,  rolled  up  snugly  from 
one  end.  Narrower  and  shorter 
strips  may  be  required  for  the 
smaller  and  more  irregular  por- 
tions of  the  body.  The  selvage 
edge  should  always  be  removed. 
•'Double-headed"  rolls  are  made 
of  longer  strips  rolled  from  each 
end  towards  the  middle ;  they  are 
used  only  for  compound  dressings 
in  whicli  the  turns  cross  each  other 
at  right  angles  (Fig.  30). 

A  bandage  should  be  so  applied 
that  it  will  press  evenly  upon  all 
portions  of  the  part  covered  by  it. 
and  not  so  tightly  as  to  cause  oedema 
of  the  distal  portion  when  applied 
to  a  limb.  When  firm  pressure  is 
needed  at  any  point  on  a  limb,  the 
bandairin^  should  beL^in  at  its  lower 
extremity  and  be  carried  up  to  the 
necessary  height.     The  methods  of 


L'ontinauue  or  spiral  bandage. 


44 


THE    ACCESSORIEIS    OF    AN    OPERATION. 


application  in  common  use  are  the  continuous  or  spiral^  the 
fi(jure  of-S  or  spira.  the  T-bandage,  the  capelUne^  and  the 
triangular  bonnet. 

The  eontinuous  or  spiral  bandage  (Fig.  24),  when  ap- 
plied to  a  limb,  should  be  fixed  by  one  or  two  circular  turns 
about  the  foot  or  hand,  and  then  carried  regularly  up  the 
limb,  each  turn  covering  the  upper  half  of  the  preceding  one. 
The  increase  in  the  thickness  of  the  limb  makes  it  necessary 
to  reverse  the  turns  in  order  that  they  may  lie  snug  and 
keep  their  place ;   this  is  done  by  fixing  the  centre  of  the 


Fig.  25. 


"  Eeversing"  tlie  turns. 

band  with  the  finger  (Fig.  25),  and  turning  over  that  edge 
of  the  bandage  which  lies  upon  the  thicker  side. 

The  figure-of-S,  or  spiea,  bandage  is  represented  in  Figs. 
26  and '27;  successive  turns  are  taken  about  two  adjoining 
parts,  crossing  from  one  to  the  other  over  the  point  which  it 
is  especially  desired  to  secure.  At  the  groin  the  bandage  is 
fixed  by  one  or  two  turns  about  the  thigh,  then  carried 
around  behind  the  back  and  across  the  hypogastrium  to  the 
thifh  again,  and  thence  over  the  same  course  as  often  as  is 
necessary. 

The  knee,  shoulder,  elbow,  or  ankle  can  be  dressed  by 


BANDAGES. 


45 


means  of  overlji])])iiio;  turns  of  a  figui'c-of-8  bandage,  or  in 
tlio  innnncM"  slioAvii  i)i  Fiu:.  28,  by  tearinL^  an  oblong  piece  of 


Fi(i.  ii(i. 


Fici.  '11. 


Spica  of  the  shoulder. 


Spica  of  the  groiu. 


muslin  down  tbe  middle  at  each  end,  leaving  a  square  un- 
divided portion  in  the  centre.     The  square  portion  is  placed 


Fig.  28. 


Four-tailed  bandage  for  the  kuee. 


over  tlie  knee,  and  the  four  ends  crossed  under  it  brought  in 
front  and  tied. 


46 


THE    ACCESSORIES    OF    AN    OPERATION. 


The  T-bandage  (Fig.  29)  is  composed  of  a  transverse  and 
one  or  two  vertical  bands.  Sometimes  the  transverse  hand 
covers  the  dressing,  and   the  vertical  band   serves  only  to 


Fig.  29. 


T-bandajre. 


keep  the  other  in  place;  but  generally  the  reverse  is  the 
case,  and  the  vertical  band  supports  a  dressing  or  an  instru- 
ment, and  is  itself  supported  by  the  transverse  one.     This 


Fig.  30. 


Capelline  or  scalp  baiKlage. 


bandage  is  most  commonly  employed  in  dressings  applied  to 
the  anus,  perineum,  and  lower  portion  of  the  trunk. 


15ANDAGES 


47 


The  rapelUne  or  scalp  handatje  (Fig.  30)  is  ap|ilie<l  bv 
meiuisof  a  douMo-lu'aded  ioIUt  bainlagc.  tlie  centre  <»f  which 
is  phice<l  upon  the  t"orehea<l  and  tlie  two  ends  c;iiTied  liori- 
zontally  around  tlie  head  to  meet  at  the  occijmt,  where  they 
cross,  and  the  lower  one  is  brought  forward  over  tlie  vertex, 
while  tlie  otiier  is  continued  amund  horizontal! v.  When 
thev  meet  a-iain  in  fi'ont  the  one  that  crosses  the  vertex  is 
carried  under  the  other  and  then  back  across  the  vertex  to 
the  occiput,  and  so  on  until  the  entire  scalp  is  covered.  This 
bandage  is  difficult  to  ap}»ly,  and  easily  disarranged.  l)ut  it  is 
useftil  when  pressure  must  be  applied  at  several  jtoints.  In 
other  cases  it  mav  be  advantacreouslv  replaced  by  the  trian- 
gular  bonnet,  or  four-taileil  bandage  (Fig.  31). 


Fig.  32. 


I 

Fuar-taile«l  Landa^  for  the  head. 




., 

— 

~j 

1 

ii 

I! 

AT^\ 

TriaDguLir  buuuet. 


Tlie  trinngular  bonnet  is  made  of  a  large  s«[uare  juece  of 
muslin  folded  diagonally  (Fig.  32).  When  applied  to  a 
stump  the  end  of  the  limb  is  placed  in  its  centre,  the  long 
fohled  border  brought  around  transvereely  and  tied,  and  the 
angle  brought  up  in  front  and  made  fast  to  it.  When  used 
as  a  susi»ensory  for  the  testicles  (Fig.  33),  two  or  three  turns 
of  a  bandage  are  passed  around  the  abdomen  and  fostened ; 
the  square  angle  of  the  triangle  is  made  fast  to  this  band  in 
front,  and  its  body  l»rought  down  in  front  of  the  scrotum, 
carried  back  behind  it,  and  the  ends  tied  to  the  transverse 
band. 


48 


THE    ACCESSORIES    OF    AX    OPERATION. 


Fig.  33. 


Suspensory  bandage. 


ImmovaJilc  hanchf'/es  are  used  mainly  in  fi-aetures.  di.<lo- 
eations,  sprains,  and  after  operations  that  have  involved  a 
joint  or  destroyed  the  continuitv  of  a  bone.  They  are  usu- 
ally made  by  soakinpr  roller  bandages  before  their  application 

in  solutions  of  starch,  dextrine, 
planter  of  Paris,  silicate  of  soda  or 
potash,  or  in  iilue.  Plaster  of  Paris 
is  the  material  most  commonly  em- 
ployed, for  it  is  cheap  and  easily 
obtained  and  prepared.  The  most 
convenient  method  of  using  it  is 
to  make  roller  bandages  of  some 
thin,   open-meshed    material,  such 

\V\      /ii^\>7       \      ^^  cross-barred  muslin  or  crinoline, 
\^yj^//         1      and  rub  the  dry  plaster  well  into 
■^  '     them  before  rolling  them  up.  When 

I'equired  for  use  the  roller  is  thor- 
oughly wet  by  placing  it  in  a  basin 
of  water,  gently  squeezed,  and  then 
rapidly  applied  to  the  limb,  while 
the  successive  turns  are  rubbed 
smooth  with  the  wet  hand.  Before  the  plaster  is  applied 
the  limb  should  be  covered  with  a  thin  layer  of  raw  cotton, 
or  with  a  few  turns  of  an  ordinary  bandage.  If  crinoline 
cannot  be  obtained  ordinary  bandages  must  be  unrolled, 
drawn  through  a  thin  mixture  of  plaster,  rolled  up  again, 
and  rajiidly  applied  before  the  plaster  has  had  time  to  set. 

Starch  should  be  spread  upon  strips  of  coarse  paper, 
which  are  then  applied  longitudinally  to  the  limb ;  silicate 
of  soda  or  potash,  dextrine,  and  glue  are  employed  by  first 
rolling  up  the  orthnary  l^andages  in  the  solution,  and  then 
applying  them  in  the  usual  manner,  or  the  band  may  be 
applied  dry  and  the  mixture  rubbed  on  each  successive 
layer.  The  skin  must  be  protected  by  a  layer  of  cotton  or 
a  few  turns  of  a  dry  bandage.  The  silicates  and  the  glue 
dry  quite  rapidly,  the  starch  and  the  dextrine  much  more 
slowly.  The  dextrine  can  only  be  dissolved  by  first  mixing 
it  with  alcohol,  and  then  adding  hot  water  and  stirrinir  it 
until  it  is  reduced  to  the  proper  consistency.  Two,  or  at 
most  three,  layers  of  bandase  are  usually  sufficient. 

A  convenient  method  of  employino:  plaster  in  the  fonn  of 


BANDAGES  49 

splint  without  covering  tlie  liuib  t-ntirely,  is  one  in  general 
use  in  the  Paris  hospitals.  A  strip  of  crinoline,  folded  in  six 
or  eight  thicknesses  of  the  proper  length  and  breadth,  is 
dniwn  through  the  liquid  plaster,  stripped  down  rapidly  to 
remove  the  excess,  applied  to  the  limb,  and  fixed  with  a  few- 
turns  of  an  onlinarv  roller  banda^re.  Instead  of  a  sintrle 
strip  two  may  be  used  and  applied  on  opposite  sides  of  the 
limb.  Such  a  splint  fits  the  limb  accurately,  and  will  not 
make  undue  pressure  at  *iny  point. 

Sayre's  Plaster  of  Paris  Jacket} — In  connection  with 
this  subject,  and  in  view  of  the  importance  and  recent  origin 
of  this  method  of  treating  spinal  disease,  it  ha.s  been  thought 
proper  to  add  a  description  of  the  method  of  applying  the 
Plaster  of  Paris  jacket. 

The  bandacres  are  made  of  strips  of  crinoline  three  vards 
long  and  from  two  and  a  half  to  tliree  inches  wide,  accord- 
ing to  the  size  of  the  patient,  filled  with  dry  plaster  as 
before  described,  and  put  up  in  rolls  which  are  moistened 
by  setting  them  on  end  in  a  basin  of  water  just  before  they 
are  to  be  applied.  For  the  purpose  of  strengthening  the 
jacket  and  diminishing  the  amount  of  plaster  required, 
narrow  strips  of  tin,  roughened  on  both  sides  like  a  nutmeg 
grater,  are  placed  longitudinally  around  the  body  at  inter- 
vals of  two  or  three  inches  between  the  turns  of  the  plaster 
bandage.  The  skin  should  be  protected  by  an  elastic,  closely 
fitting  undei^shirt  of  some  soft  woven  or  knitted  material, 
without  arms,  but  with  tabs  to  tie  over  the  shoulders. 

As  it  is  difficult  for  an  assistant  to  hold  the  patient  sus- 
pended during  the  application  of  the  dressing,  the  apparatus 
shown  in  Fig.  34  has  been  devised.  It  consists  of  a  curved 
iron  cross-bar,  to  which  are  attached  an  adjustable  head  and 
chin  collar  and  axillaiy  bands.  To  a  hook  in  the  centre  is 
attached  a  compound  pulley,  the  other  end  of  which  is 
secured  either  to  a  hook  in  the  ceiling  or  to  the  top  of  a 
tripod  eight  or  ten  feet  high  (Fig.  35). 

The  collar  and  bands  having  been  carefully  adjusted,  the 
patient  is  drawn  up  until  the  feet  swing  clear  of  the  floor, 
and  a  wedge-sha]»e<l  pad  of  raw  cotton  folded  in  a  handker- 

^  Spinal  Disease  and  Spinal  Curvature,  by  Prof.  L.  A.  Sayre,  1877. 

5 


50 


THE    ACCESSORIES    OF    AN    OPERATION. 


chief  is  placed  over  the  abdomen  between  tlie  sliirt  and  tlie 
skin,  its  thin  edge  directed  downward.  Tliis  is  intended  to 
leave  room,  when  removed,  for  the  distention  of  the  abdomen 
after  meals.  It  is  important  to  make  the  pad  thin  where  it 
lies  under  the  lower  edge  of  the  jacket,  for  otherwise  the 
latter  would  fit  too  loosely. 


Fig.  34. 


Fig.  no. 


Suspensory  apparatus. 


Tripod. 


If  the  skin  covering  any  bony  prominences  has  become 
irritated,  it  must  be  protected  by  small  pads  of  raw  cotton 
or  cloth  placed  on  either  side;  and  it  is  well  also  to  place 
pads  of  two  or  three    thicknesses  of  cloth,  three   or  four 


BANDAGES. 


51 


iiK'lu's  long,  over  each  anterior  iliac  spine,  removing  them 
het'ore  the  plaster  has  set. 

It*  the  patient  is  a  female,  and  especially  if  she  is  just 
reaching  the  age  of  puberty,  a  pad  of  cotton  in  a  handker- 
chief must  ])e  placed  over  each  mamma,  and  withdrawn 
before  the  jdaster  has  set. 

The  undershirt  having  been  tied  over  the  shoulders, 
pulled  down,  and  kept  stretched  by  means  of  tapes  fastened 
to  its  lower  edi^e  in  front  and   behind,  and  tied   together 


Fig.  3G. 


Patient  suspended  ready  for  the  plaster. 


tightly  over  a  handkerchief  placed  on  the  perineum,  the 
patient  is  slowly  drawn  up  by  means  of  the  apparatus  until 
he  feels  perfectly  comfortable,  and  never  hei/ond  that  j^oint, 
and  kept  in  this  position  (Fig.  36)  until  the  bandage  has 
been  applied. 


52         THE    ACCESSORIES    OF    AN    OPERATION. 

The  bandage  is  first  carried  around  the  smallest  part  of 
the  body,  then  around  and  around  downward,  to  and  a  little 
beyond  the  crest  of  the  ilium,  and  afterward  from  below 
upward  spirally  until  the  entire  trunk  from  the  pelvis  to 
the  axilla  has  been  encased.  It  must  be  applied  smoothly 
and  not  drawn  tight ;  it  should  be  simply  unrolled  with  one 
hand,  while  the  other  follows  and  brings  it  into  smooth  close 
contact  with  all  the  irregularities  of  tlie  surface  of  the 
trunk.  After  one  or  two  thicknesses  of  bandage  have  been 
thus  applied,  the  strips  of  tin  are  laid  on,  and  another  layer 
placed  over  them.  In  a  very  short  time  the  plaster  sets 
with  sufficient  firmness  to  allow  the  patient  to  be  removed 
from  the  suspending  apparatus,  and  laid*  upon  his  fice  or 
back  on  a  firm  mattress.  The  abdominal,  iliac,  and  breast 
pads  are  then  removed,  and  the  plaster  gently  pressed  in 
with  the  hand  in  front  of  each  spinous  process  of  the  ilium. 
If  any  weak  spots  appear  they  must  be  strengthened  by 
wetting  the  surface  and  dusting  on  more  plaster. 

If  abscesses  or  ulcers  are  present  they  must  be  covered 
with  a  large  piece  of  oil-silk,  and  a  hole  cut  in  the  under- 
shirt at  the  proper  point  before  the  bandage  is  applied. 
Then,  before  the  plaster  has  entirely  hardened,  a  fenestra 
is  cut  with  a  knife,  the  oil-silk  cut  in  strips  fi'om  the  centre 
of  the  opening  to  the  edge,  and  the  strips  turned  back  and 
glued  fast  to  the  plaster  with  shellac. 


PART    II. 


LIGATL'KK  OF  THK  AKTKlilK 


GENERAL    DIRECTIONS. 


A  POINT  for  the  application  of  the  liiiature  should  be 
chosen,  if  possible,  not  nearer  than  half  an  inch  to  any 
collateral  branch  above  or  below  it.     The  operator  should 


Fig.  37. 


This  diagram  represents  three  ilistiuct  operations. 

A.  Opening  the  sheath.  B.  Drawing  ligature  round  the  artery. 

C.  Tying  artery. 

make  him.self  thoroughly  familiar  with  the  anatomical  rela- 
tions of  the  parts  and  the  landmarks  of  the  operation ;  he 
should  proceed  methodically,  in  accordance  with  a  definite 
plan,  and  seek  for  and  recognize  each  layer,  each  landmark 
in  its  order. 


54 


LIGATURE    OF    THE    ARTERIES. 


It  is  well  to  mark  upon  the  skin  with  ink  or  iodine  the 
line  of  the  proposed  incision ;  the  incision  should  be  fi'ee, 
and,  so  far  as  possible,  its  centre  should  correspond  with 
the  point  at  which  the  ligature  is  to  be  applied.  The  first 
incision  should  o-o  fairly  throuirh  the  skin,  and  then  be  car- 
ried  down  to  the  enveloping  fascia  by  repeated  applications 
of  the  knife.  The  fascia  should  be  pinched  uj),  nicked,  and 
divided  upon  a  director  if  the  vessels  lie  immediately  below 
it,  or  upon  the  finger  if  a  muscular  interstice  is  to  be  sought 
for.  The  division  of  the  fascia  should  equal  in  length  the 
external  incision. 

The  knife  is  then  laid  aside  and  the  arterv  souo:ht  for  bv 
separating  the  tissues  with  the  fingers  or  a  director.  The 
sheath  is  recognized  by  the  communicated  pulsation,  and 
by  the  absence  of  the  pinkish-white  color  and  smooth  shining 
surface  which  characterize  the  artery.  AY  hen  found,  it  is 
gently  pinched  up  with  the  forceps,  the  flat  of  the  knife 
laid  upon  it,  and  a  hole  one-quarter  of  an  inch  long  care- 
fully made  in  it.  A  distinct  sheath  is  found  only  about  the 
main  trunks,  and  is  replaced  in  the  others  by  a 
layer  of  cellular  tissue,  which  is  more  readily 
separated  by  tearing  with  the  point  of  a  director 
or  with  two  forceps. 

When  the  pinkish-white  coat  of  the  vessel  has 
been  fairly  exposed,  each  edge  of  the  hole  in  the 
sheath  is  grasped  in  turn  with  forceps,  and  the 
sides  of  the  vessel  gently  separated  from  the 
sheath  by  tearins:  through  the  sliorht  attachments 
with  the  point  of  a  director. 

A  threaded  aneurism  needle  is  then  entered  on 

that  side  where  the  parts  lie  that  are  most  to  be 

avoided,  and  passed  behind  the  artery,  care  being 

taken  not  to  raise  the  latter  from  its  bed,  until  its 

eye  appears  upon  the  other  side ;    the  thread  is 

then  picked  up  with  forceps  and  drawn  through 

while  the  needle  is  withdrawn.      The  precaution 

should  never  be  omitted  of  trying  if  compression 

needle.        of  the  vcsscl  betwecu  the  fin2:er  and  the  ligature 

arrests  pulsation  in  its  distal  branches,  for  the  best 

surgeons  have  mistaken  a  nerve  or  strip  of  fascia  for  the 

artery.     The  main  trunks  can  be  readily  distinguished  from 


Fig.  38. 


GENERAL    DIRECTIONS. 


55 


tlio  veins  by  their  api)earance — tlie  veins  resembling  a  leecli, 
wliik'  tlie  arteries  are  wliite  and  feel  like  a  conl  or  ban*! 
un<ler  the  finger — and  by  their  known  anatomical  relations; 
but  it  is  often  very  difficult  to  recojinize  the  smaller  arte- 
ries,  since  they  closely  resemble  the  veins.  The  operator 
has  to  depend  upon  three  indications:  1,  the  fact  that 
when  there  are  two  satellite  veins  the  artery  is  placed  be- 
tween them :  2,  pulsation  ;  3,  alternate  compression  of  the 
vascular  bundle  at  the  .two  ends  of  the  incision.  Pressure 
at  the  proximal  end  causes  the  artery  to  shrink  and  the 
veins  to  swell;  pressure  at  the  distal  end  has  the  contrary 
effect. 

The  ligature  is  then    tied  with  a  square  knot  (Fig.  2), 
tightly  enough  to  cut  the  inner  coats  of  the  vessel,  and  one 


Fig.  39. 


'*  a.  Tuner  c«^t  uf  an  artfrv  ruptured  l-y  a  ligaluiv. 

or  both  ends  cut  short,  according  to  the  material  used.  If 
antiseptic  catgut  or  silk  is  used,  both  ends  may  be  cut  short 
and  the  wound  closed.  The  catgut  is  soon  absorbed,  and  it 
has  been  proved  that  silk  thus  prepared  is  unirritating,  and 
does  not  cause  suppuration.  The  lymph  thrown  about  these 
ligatures  gives  strength  to  the  wall  of  the  vessel  and  addi- 
tional   security    against    secondary    hemorrhage.      Primary 


56  LIGATURE    OF    THE    ARTERIES, 

union,  at  least  of  the  deep  parts  of  the  wound,  may  be  con- 
fidently expected. 

If  unprepared  silk  is  used,  only  one  end  of  the  ligature  is 
cut  short ;  the  other  is  brought  out  through  the  wound, 
which  then  remains  open  until  after  the  ligature  has  cut 
through  the  artery  and  been  thrown  off  by  suppuration. 

While  making  the  incisions  the  position  of  the  parts 
should  be  such  that  the  muscles  which  serve  as  guides  shall 
be  tense,  but  while  seeking  for  the  artery  the  muscles  should 
be  relaxed  so  as  to  give  more  room. 


ANATOMY  OF  THE  SUPRA-CLAVICULAR  REGION. 

The  superficial  fascia  underlies  the  platysma,  and  incloses 
the  sterno-cleido-mastoid  in  a  reduplication  of  itself.  The 
middle,  or  sterno-clavicular,  fascia  has  a  common  origin  with 
the  superficial  fascia  in  the  linea  alba  between  the  two 
sterno-thyroid  muscles,  divides  into  three  layers  to  form 
sheaths  for  the  sterno-thyroid  and  sterno-hyoid,  unites,  and 
attain  divides  to  form  a  sheath  for  the  omo-hyoid,  unites 
ao-ain  and  finally  joins  the  superficial  fascia  between  the 
trapezius  and  sterno-cleido-mastoid.  This  middle  fascia  is 
strong  and  resisting,  and  incloses  all  the  vessels  of  the 
reo-ion  except  the  external  jugular  vein,  which  is  subcuta- 
neous throughout  its  course  until  it  turns  inward  to  join  the 
subclavian  above  the  clavicle.  These  two  fascij:e  are  sepa- 
rated from  each  other  and  from  the  skin  by  loose  cellular 
tissue,  in  which  a  large  amount  of  fat  may  be  deposited, 
and  it  is  of  prime  importance  therefore  that  they  should  be 
recoo-nized  in  the  search  for  the  vessels. 

The  vessels  which  are  approached  through  this  region  are 
the  innominate,  the  subclavian,  and  the  common  carotid. 
The  bifurcation  of  the  innominate  corresponds  with  the 
sterno-clavicular  articulation,  and  in  old  people,  as  well  as 
in  exceptional  cases,  rises  from  five  to  ten  millimetres  above 
it.  It  lies  in  front  and  on  the  right  side  of  the  trachea, 
and  is  crossed  anteriorly  by  the  left  innominate  vein.  At 
the  bifurcation  the  subclavian  lies  behind  and  to  the  outer 
side  of  the  carotid,  and  is  crossed  by  the  pneumogastric  and 
phrenic  nerves  close  to  its  origin,  the  former  giving  off  the 


LIGATURE    OF    INNOMINATE    ARTERY.  57 

recurrent  l;iryn<^e:il  ^vliicli  turns  under  tlie  ;irtery  and  rises 
again  beliind  it.  The  carotid,  ■\vliicli  at  first  lies  behind  the 
sterno-cleido-mastoid,  soon  reaches  its  anterior  edge,  and 
at  the  same  time  increases  its  distance  from  the  trachea. 
While  the  internal  jui!:ular  lies  Avholly  within  the  middh- 
cervical  fascia,  the  subclavian  vein  is  enveloped  by  a  redu- 
plication of  it  and  held  closely  against  the  clavicle  thereby. 
It  is  therefore  more  superficial,  and  on  a  lower  plane  than 
the  curved  portion  of  the  subclavian  artery,  and  need  not 
be  uncovered  in  the  search  for  the  latter.  The  branches  of 
the  subclavian,  seven  in  number,  arise  (with  one  exception, 
the  transversalis  colli)  from  its  first  portion,  that  comprised 
between  its  origin  and  the  inner  border  of  the  scalenus  an- 
ticus.  The  transversalis  colli  may  arise  from  the  first  part, 
or  the  second  (between  the  scaleni),  or  even  the  third 
(beyond  the  scaleni).  The  supra-scapular  crosses  in  front 
of  the  scalenus  anticus  and  runs  doAvnward  and  outward 
to  the  clavicle,  lying  below  the  line  of  the  incision  made  in 
tying  the  subclavian  in  its  third  portion. 


LIGATURE  OF  THE  INNOMINATE  ARTERY. 

Anatomy. — The  artery  is  in  relation  in  front  with  the 
innominate  veins  and  the  pneumogastric  nerve ;  on  the 
inner  side  with  the  trachea ;  on  the  outer  side  and  behind 
with  the  pleura.  It  lies  immediately  l)ehind  the  sterno- 
clavicular articulation. 

Five  different  incisions  have  been  proposed.  A  vertical 
one  in  the  middle  of  the  neck  (King) ;  a  horizontal  one  4J 
inches  long,  beginning  in  the  middle  line  and  passing  out- 
ward parallel  to  and  half  an  inch  above  the  clavicle  (Ma- 
nec) ;  an  oblique  one  in  the  interval  between  the  sternal 
and  clavicular  attachments  of  the  sterno-cleido-mastoid 
(Sedillot) ;  an  oblique  one  from  the  anterior  border  of  the 
left  sterno-cleido-mastoid  2J  inches  above  the  clavicle  down 
to  and  a  little  beyond  the  left  sterno-clavicular  articulation 
(Velpeau);  a  V-shaped  one,  of  which  one  side  lies  over  the 
anterior  edge  of  the  sterno-cleido-mastoid,  and  the  other  is 
parallel  to  and  a  little  above  the  clavicle  (Mott).  The  single 
incisions  do  not  give  sufficient  room,  and  although  they  are 


58 


LIGATURE    OF    THE    ARTERIES, 


more  brilliant  they  should  give  Avay  to  the  more  j^rudent 
and  practical  one  proposed  by  Mott. 

Operation. — An  incision  8J  inches  in  length  is  carried 
along  the  anterior  edge  of  the  right  sterno-cleido-mastoid, 
ending  half  an  inch  above  the  sternum  (Fig.  40).  Another, 
of  the  same  length,  is  carried  outward  from  the  lower  end 
of  the  first,  half  an  inch  above  and  parallel  to  the  right 
clavicle.  These  incisions  are  carried  down  to  the  superficial 
fascia,  and  the  triangular  flap  between  them  dissected  up. 

Fig.  40. 


Liyature  of  arteries.  A.  Innominate.  B.  2cl  or  3cl  portion  of  subclavian.  C.  2il  or  3d 
portion  of  subclavian  (Skey)  D.  Vertebral  or  inferior  thyroid.  E.  Axillary  below  the 
clavicle. 

If  the  anterior  jugular  is  encountered  it  must  be  drawn 
downward.  The  sternal  and  part  of  the  clavicular  attach- 
ments of  the  sterno-cleido-mastoid  are  now  divided  half  an 
inch  above  the  bone  on  a  directer  or  with  forceps  and  knife, 
and  the  muscle  drawn  upward  and  outward,  uncovering  the 
sterno-thyroid  and  sterno-hyoid  and  the  middle  cervical 
fascia  which  here  is  very  dense  and  covered  by  the  inferior 
thyroid  veins.  The  outer  fibres  of  the  sterno-hyoid  and 
sterno-thyroid   are   now  divided,   the   thyroid  veins   drawn 


LIGATURE    OF    THE    SUBCLAVIAN    ARTKKY.      59 

aside,  aiul  tlu-  uiKUTlying  or  middle  fascia  torn  tlirou;:li 
with  tlu'  «liiV(.-tor,  or  opened  verv  caivf'iiUy  with  tlit-  knife. 
The  common  carotid  is  now  seen  at  tlie  bottom  of  the  wound 
and  traced  downward  to  the  inn<»minate.  The  internal 
jugular  is  carefully  pressed  outward  with  a  retractor :  the 
left  forefinger,  passed  into  the  wound  between  the  artery 
and  the  innominate  veins,  presses  the  latter  against  the 
sternum,  and  the  operator  proceeds  carefully  to  clean  the 
artery  with  a  director  half  an  inch  below  its  bifurcation. 
The  needle,  guided  by  tfie  finger,  is  passed  from  the  outer 
side  so  as  to  avoid  the  vein,  nerve,  and  i)leura. 

The  innominate  has  been  tied  only  for  aneurism  of  itself, 
of  the  subclavian,  or  of  the  primitive  carotid.  With  one 
exception,  the  case  of  Dr.  Smyth,  of  New  Orleans,  the  ope- 
ration has  terminated  fatally  in  every  case ;  and,  as  it  has 
been  shown^  that  the  treatment  of  aneurism  bv  distal  li^a- 
ture  yields  satisfactory  results,  this  operation  is  seldom 
justifiable.  It  may  be  rendered  necessary  by  hemorrhage 
from  the  subclavian  or  carotid,  but  the  attempt  should  always 
be  made  to  tie  the  injured  vessel  in  the  wound  before  resort- 
ing to  so  dancrerous  a  method  as  liojature  of  the  innominata. 


LIGATURE  OF  THE  SUBCLAVIAN  ARTERY. 

The  anatomical  difference  between  the  right  and  left  sub- 
clavian is  confined  to  the  first  portion  of  the  artery,  which 
in  the  left  is  much  longer,  more  vertical  in  its  direction,  and 
situated  more  posteriorly  even  than  the  innominate;  a  sepa- 
rate description  therefore  is  required  only  for  the  first 
portion. 

\st  Portion.  Left Suhdav inn. — This  operation,  attempted 
unsuccessftilly  by  Astley  Cooper  about  1820.  has  been 
generally  deeme<l  unjustifiable  on  account  of  the  supposed 
impossibility  of  avoiding  the  thoracic  duct  and  the  pleura. 
It  was.  however,  tied  successfully  by  Dr.  J.  Kearny  R<Hlgers, 
of  New  York,  in  1845,  the  patient  dying  on  the  fifteenth 
dav  from   hemorrhaore ;   and   recentlv   McGill,'  of  Leeds, 

'  Prof.  W.  H.  Vrtn   Buren,  On  Aneurism.     Paper  read  before  the 
International  Medical  Congress,  Philadelphia,  1870. 
2  Med  -Chir.  Trans.,  vol.  58,  p.  338. 


60  LIGATURE    OF    THE    ARTERIES. 

England,  laid  bare  the  artery  after  a  tedious  and  difficult 
dissection  and  applied  metallic  compression  just  below  the 
oricrin  of  the  vertebral  artery  for  eiorht  hours.  The  aneurism 
was  quite  filled  by  a  firm  coagulum.  but  unfortunately  the 
pleura  had  been  perforated  during  the  operation,  and  the 
patient  died  of  pleurisy  on  the  sixth  day.  Dr.  Rodgers's 
case  shows  that  the  artery  can  be  tied  without  injury  to  the 
pleura  or  thoracic  duct,  and  Mr.  McGills  shows  that  its 
temporary  occlusion  is  sufficient  to  consolidate  the  aneurism. 
In  Mr.  McGills  case  the  artery  seemed  to  be  abnormally 
placed,  and  was  found  with  much  difficulty  at  a  depth  of 
about  three  inches.  Under  more  favorable  circumstances 
the  artery  might  be  exposed  as  successfully  as  was  done  by 
Dr.  Rodgers,  and  metallic  compression  or  a  temporary  liga- 
ture, not  drawn  tightly  enough  to  injure  the  inner  coats  of 
the  vessel,  might  cause  consolidation  of  the  aneurism  with- 
out exposure  to  the  danger  of  secondary*  hemorrhage. 

Operation. — A  Y-s^haped  incision  similar  to  that  described 
for  ligature  of  the  innominata  (Fig.  40)  is  made  upon  the 
left  side,  and  carried  through  the  sterno-cleido-mastoid  and 
outer  fibres  of  the  sterno-thyroid  and  sterno-hyoid  muscles 
and  the  middle  cervical  fascia  as  before  described.  The 
carotid  is  then  recocjnized,  and,  together  with  the  internal 
jugular,  drawn  outward  with  a  blunt  hook.  The  muscles 
are  now  relaxed  by  bending  the  head  and  neck  forward, 
and  the  cellular  tissue  torn  through  with  forceps  and  direc- 
tor. The  knife  should  no  longer  be  used,  on  account  of  the 
risk  of  injury  to  the  thoracic  duct,  which  is  embedded  in  the 
loose  tissue  between  the  vessels  and  the  vertebrae,  and  is 
rendered  very  difficult  of  recognition  by  its  small  size  and 
thin  walls.  It  runs  directly  across  the  route  to  the  artery 
while  passing  from  the  bodies  of  the  vertel)rLe  to  the  ante- 
rior border  of  the  scalenus  anticus,  and  can  be  best  avoided 
by  making  the  search  below  and  to  the  outer  side  of  it  in 
the  lower  angle  of  the  wound. 

The  finger,  passed  downward  and  backward  behind  the 
carotid,  soon  feels  the  artery  by  pressing  it  against  the  side 
of  the  spinal  column,  the  loose  cellular  tissue  surrounding  it 
is  easily  separated  with  the  director,  the  vessel  cleaned,  and 
the  needle  passed  from  the  inner  side.     The  needle  should 


LIGATURE    OF    THE    SUBCLAVIAN    ARTERY.      61 

have  a  short  curve,  and  its  jioint  should  be  kept  close  against 
the  vessel  so  as  to  avoid  injuring  the  j)leiira. 

1.^^  J^ortion.  lii()ht  Subclavian. — The  first  portion  of  the 
I'iirht  subclavian  has  been  tied  unsuccessfully  by  Colles, 
Mott,  and  Jjiston.  It  is  exposed  in  the  same  manner  as  the 
innominate  artery,  and  the  ligature  passed  from  the  outer 
side,  the  pneumogastric  and  phrenic  nerves  being  pressed 
inward  toward  the  carotid.  ^J'he  great  danger  of  this  o|)e- 
ration  lies  in  the  proximity  of  collateral  branches. 

2d  Portion. — This  operation,  first  proposed  and  per- 
formed by  Dupuytren,  is  rendered  dangerous  by  the  fact 
that  one,  and  sometimes  several  large  branches  are  given 
off  from  this  part  of  the  artery.  The  preliminary  steps  are 
the  same  as  those  employed  in  ligature  of  the  3d  portion ; 
after  the  mi(hlle  cervical  fascia  has  been  divided,  the  tu- 
bercle of  the  first  rib  and  the  external  border  of  the  scalenus 
anticus  are  sought,  the  muscle  bared  and  divided  upon  a 
director,  the  phrenic  nerve  which  lies  upon  its  anterior 
aspect  being  carefully  avoided.  As  soon  as  the  muscular 
fibres  are  cut  they  retract  and  leave  the  artery  in  full  view. 

3c?  Poi'tion.  Anatomy. — The  3d  portion  of  the  subcla- 
vian lies  between  the  outer  border  of  the  scalenus  anticus 
and  the  tubercle  of  the  first  rib  in  front  and  the  brachial 
plexus  behind,  and  below  the  posterior  belly  of  the  omo- 
hyoid ;  it  is  crossed  on  a  much  more  superficial  plane  by  the 
external  jugular,  which  enters  the  subclavian  near  the  mid- 
dle of  the  clavicle.  In  muscular  sidjjects  the  clavicular 
insertions  of  the  trapezius  and  sterno-cleido-mastoid  muscles 
lie  near  to,  or  may  even  join,  one  another;  in  others,  they 
are  from  two  to  three  inches  apart.  Ordinarily  the  vessel 
lies  at  a  depth  of  one  or  one  and  a  half  inches  below  the 
surfiice,  but  in  very  fjit  persons,  or  when  the  clavicle  has 
been  pushed  upward  by  an  axillary  aneurism,  this  distance 
may  be  increased  to  three  inches. 

Operation. — Beginning  an  inch  outside  of  the  sterno- 
clavicular articulation,  make  an  incision  three  or  four  inches 
long  parallel  to  and  half  an  inch  above  the  clavicle  (Fig. 
40,  B).     Divide  the  skin  and  the  platysma ;  when  the  ex- 

6 


62  LIGATURE    OF    THE    ARTERIES. 

ternal  jugular  is  exposed  draw  it  to  the  inner  side  or  divide 
it  between  two  ligatures.  Divide  on  a  director  the  super- 
ficial fascia,  and  the  clavicular  portion  of  the  mastoid  muscle 
if  necessary,  and  seek  the  posterior  belly  of  the  omo-liyoid. 
Draw  this  muscle  outward  and  upward,  and  feel  for  the 
tubercle  of  the  first  rib,  following  down  the  outer  border  of 
the  scalenus  anticus.  Depress  the  shoulder  as  much  as 
possible,  denude  the  artery  with  the  finger-nail  or  the  point 
of  a  director,  and  pass  the  needle  from  below,  taking  care 
not  to  include  the  lowest  bundle  of  the  brachial  plexus  in 
the  lio;ature.  In  order  to  avoid  mistakinir  this  bundle  for 
the  artery,  the  tubercle  of  the  first  rib  should  always  be 
found ;  the  artery  lies  against  it,  between  it  and  the  nerve. 

Skey  prefers,  in  difficult  cases,  a  curved  incision  "com- 
menced about  two  and  a  half  or  three  inches  above  the 
clavicle,  upon,  or  immediately  on  the  outer  edge  of,  the 
mastoid  muscle.  This  incision  is  carried  slightly  outward 
and  downward,  toward  the  acromion,  and  then  curved  in- 
ward alonor  the  clavicular  orisin  of  the  mastoid  muscle.'" 
(Fig.  40,  C.)  Ordinarily  the  external  jugular  is  left  to  the 
outer  side  of  the  incision. 


LIGATURE  OF  THE  IXFERIOR  THYROID. 

Anatomy. — After  passing  vertically  upward,  the  artery 
curves  inward  to  reach  the  under  surfiice  of  the  thvroid  orland. 
The  highest  point  of  its  curve  is  half  an  inch  below  the 
prominence  on  the  transverse  process  of  the  sixth  cervical 
vertebra,  named  by  Chassaignac  the  carotid  tubercle.  In 
old  people  it  is  somewhat  higher.  It  lies  behind  the  com- 
mon carotid  and  internal  jugular,  and  is  separated  from 
them  by  more  or  less  dense  cellular  tissue.  The  guides  to 
the  vessel  are  the  carotid  and  Chassaignac's  tubercle. 

Operation. — Make  an  incision  three  and  a  half  or  four 
inches  in  lenorth  alono;  the  anterior  border  of  the  sterno- 
cleido-mastoid,  ending  an  inch  above  the  clavicle  (Fig.  40, 
D).  Lay  bare  the  border  of  the  muscle,  and  draw  it  out- 
ward, tear  through  or  divide  the  middle  fascia  and  draw  the 
carotid  and  internal  jugular  outward  v>'ith  a  retractor.  Flex 
the  head  slightly  to  relax  the  parts,  feel  with  the  finger  for 


LIGATURE    OF    THK    AXILLARY    ARTERY.       63 

tlio  carotid  tu])cTC'U',  and  seek  tlic  arlcry  Ik'Iow  it,  scjtaratiii;!; 
tlic  cellular  tissue  with  a  director.  i*ass  the  needle  between 
the  artery  and  vein. 


LIGATURE  QF  TJIE  VERTEBRAL  ARTERY. 

Anatomy. — The  vertebral  artery  passes  from  the  first 
portion  of  the  subclavian  upward  and  backward  to  the 
transverse  process  of  the  sixth  cervical  vertebra.  It  is  ac- 
companied by  a  vein  which  lies  in  front,  and  is  covered  by 
the  deep  cervical  fascia.  The  guide  to  it  is  the  carotid 
tubercle. 

Operation. — The  first  incision  is  the  same  as  for  ligature 
of  the  inferior  thyroid  (Fig.  40,  D).  The  anterior  edge 
of  the  sterno-cleido-mastoid  is  exposed  and  drawn  outward. 
The  middle  fiiscia  is  divided,  and  the  carotid  and  jugular 
drawn  inward.  The  gap  between  the  longus  colli  and  the 
scalenus  anticus  is  then  felt  for  about  half  an  inch  below 
the  carotid  tubercle,  the  deep  fascia  covering  it  torn  through, 
the  muscles  separated,  the  vertebral  vein  pushed  aside,  and 
the  artery  exposed. 

Chassaignac  prefers  an  incision  along  the  posterior  border 
of  the  mastoid  muscle,  and  reaches  the  carotid  tubercle  by 
drawing  the  muscle  and  vessels  inward.  If  the  muscle  is 
very  broad  some  of  its  clavicular  fibres  must  be  divided. 


LIGATURE  OF  THE  AXILLARY  ARTERY. 

Anatomy.— T\n2  axillary  extends  from  the  middle  of  the 
clavicle  to  the  lower  edge  of  the  tendon  of  the  teres  major. 
The  axillary  vein  lies  on  the  inner  side  and  in  front  of  it. 
and  the  brachial  nerves  invest  its  lower  portion  closely.  It 
can  be  tied  below  the  clavicle  in  the  clavi-pectoral  triangle 
formed  by  the  clavicle,  inner  border  of  the  i)ectoralis  minor, 
and  the  thorax,  or  in  the  axilla.  The  strong  fascia  which 
unites  the  coracoid  ])rocess  and  clavicle,  and  forms  the  sus- 
pensory ligament  of  the  axilla,  the  costo-coracoid  fiiscia, 
sends  a  prolongation  about  the  upper  portion  of  the  axillary 
vein  which  keeps  its  walls  from  sinking  in ;  the  cephalic 


64 


LIGATURE    OF    THE    ARTERIES. 


vein  ascending  in  the  groove  between  the  deltoid  and  pec- 
toralis  major  perforates  this  fascia  and  joins  the  axillary 
vein  at  the  inner  border  of  the  tendon  of  the  pectoralis 
minor,  close  by  the  origin  of  the  acromial  thoracic  artery. 

A.  Ligature  under  the  Clavicle. — (Fig-  40,  U.)  Make 
an  incision  extending  from  the  summit  of  the  coracoid  pro- 
cess four  or  four  and  a  half  inches  along  the  lower  border 
of  the  clavicle.  Divide  successively  the  skin,  subcutaneous 
tissue,  superficial  fascia,  and  pectoralis  major,  and  then 
tear  carefully  through  the  costo-coracoid  fascia,  avoiding 
injury  to  the  cephalic  vein  at  the  outer  part  of  the  wound. 
The  pectoralis  minor  is  noAV  exposed,  and  after  separating  the 
cellular  tissue  with  the  point  of  a  director  the  axillary  vein 
is  seen  crossing  from  the  upper  edge  of  the  muscle  to  the 
clavicle.  The  artery  is  completely  hidden  by  it,  lying  on 
the  outer  side  and  a  little  behind.  The  vein  must  now  be 
drawn  inward,  the  needle  entered  between  it  and  the  artery, 
and  the  ligature  applied  as  near  as  possible  to  the  clavicle 
on  account  of  the  proximity  of  the  acromial  thoracic  branch. 

B.  Ligature  in  the  Axilla.  Anatomy. — The  tissues  and 
organs  on  the  outer  side  of  the  axilla  are  arranged  in  the 

Fig.  41. 


<S5^ 


A    Ligature  of  the  iixillary  artery.     B.  Ligature  of  the  brachial  artery. 


following  order:  1,  the  skin;  2,  the  subcutaneous  cellular 
tissue ;  3,  the  fascia ;  4,  the  axillary  vein ;  5,  the  internal 
cutaneous  and  ulnar  nerves;  6,  the  axillary  artery;  7,  the 
median  nerve;  8,  the  coraco-brachialis;   9,  the  humerus  and 


LIGATUKK    OF    THE    BRACHIAL    AHTKIiY.        05 

articular  c'a})8ule.  Tlic  old  ruk'  tor  exposing  the  artery 
here  was  to  make  a  loiiiritudinal  incision  at  the  junction  of 
the  anterior  and  middle  thirds  of  the  axilla,  find  the  vein, 
count  two  nerves,  and  look  for  the  artery  just  beyond  the 
la8t  one.  This  is  a  difficult  and  dangerous  method,  and  a 
much  simpler  one  has  been  substituted  by  Malgaigne,  who 
was  the  first  to  point  out  that  the  coraco-brachialis  muscle 
is  the  real  guide  to  the  artery. 

Operation. — The  arm'  is  abducted  completely,  the  incision 
connnenced  at  the  inner  border  of  the  coraco-brachialis  over 
the  head  of  the  humerus  and  carried  two  and  a  half  or 
three  inches  down  the  arm  parallel  to  the  course  of  the  artery. 
It  should  involve  the  skin  only,  so  as  to  avoid  injuiy  to  the 
basilic  vein.  If  the  edge  of  the  coraco-brachialis  cannot 
be  distiniruished,  the  incision  should  be  made  accordintj  to 
the  old  rule,  at  the  junction  of  the  inner  and  middle  thirds 
of  the  axilla.  The  aponeurosis  is  now  divided  upon  a  direc- 
tor over  the  coraco-brachialis,  and  the  fibres  of  the  inner 
border  of  this  muscle  exposed.  The  parts  are  then  relaxed 
by  bringing  the  arm  nearer  the  trunk,  and  the  posterior  side 
of  the  wound,  including  the  vein,  ulnar  and  internal  cutane- 
ous nerves,  is  drawn  back  with  a  retractor;  and  the  artery, 
overlain  by  the  median  nerve,  usually  appears  at  the  bottom, 
covered  perhaps  by  the  posterior  part  of  the  sheath  of  the 
coraco-brachialis. 


LIGATURE  OF  THE  BRACHIAL  ARTERY. 

Anatomy. — The  brachial  artery  runs  from  the  junction  of 
the  anterior  and  iniddle  thirds  of  the  axilla  to  the  middle  of 
the  anterior  aspect  of  the  elbow\  It  occupies,  when  the 
forearm  is  supinated,  the  groove  between  the  biceps  and 
triceps,  being  partly  covered  by  the  former  in  muscular  sub- 
jects, and  separated  from  the  bone  by  the  inner  edge  of  the 
coraco-brachialis,  and  of  the  brachialis  anticus.  It  lies  in 
the  anterior  loge  of  the  ann,  which  is  bounded  posteriorly 
on  this  side  by  a  prolongation  of  the  enveloping  aponeurosis, 
extending  down  to  the  bone  between  the  biceps  in  front 
and  the  triceps  behind.  It  lies,  conse(iuently,  within  the 
sheath  of  the  biceps,  and  the  inner  edge  of  this  muscle 

6* 


6Q 


LIGATURE    OF    THE    ARTERIES, 


is  the  sure  guide  to  it.  It  lies  between  two  satellite 
veins,  which  anastomose  frequently,  and  has  the  median 
nerve  in  immediate  relation  with  it  on  the  side  next  the 
skin.  The  basilic  vein  directly  overlies  it  between  the  skin 
and  the  aponeurosis.     The  artery  presents  frequent  anoma- 

FiG.  42. 


Transverse  section  of  the  arm  at  its  middle  (Tillaux).  1.  Skiu.  2.  Subcutaneous  tis- 
sue. 3.  Enveloping  aponeurosis.  4.  Aponeurosis  separating  the  anterior  and  posterior 
leges  on  the  inner  side.  5.  Division  on  the  outer  side.  6.  Brachial  artery  and  veins.  7. 
Median  nerve.  8.  Basilic  vein.  9.  Internal  cutaneous  nerNe  10.  Ulnar  nerve.  11. 
Its  artery  and  veins.  12.  ^Muscular  cutaneous  nerve.  13.  Muscular  spinil  ner\e.  14. 
Superior  profunda  artery.     15.  Cephalic  vein. 


lies.  The  most  common  is  its  premature  bifurcation  into 
the  radial  and  ulnar,  which  may  take  place  as  high  as  in 
the  axilla,  in  which  case  one  of  the  branches  is  superficial, 
perhaps  even  subcutaneous,  while  the  other  follows  the  usual 


LIGATURE    OF    THK     RADIAL    ARTERY 


67 


coiii'se.  The  inudiaii  nerve  occupies  tlie  same  sheath  witli 
the  arterv,  l.ving  first  on  the  outer  side  and  then  crossing, 
in  front  or  behind,  very  obliquely  to  the  inner.  The  ulnar 
nerve,  accompanied  by  an  arterv  and  two  veins,  lies  in  the 
substance  of  the  triceps  immediately  behind  the  brachial 
arterv  and  median  nerve,  separated  from  them  only  by  the 
above-mentioned  prolongation  of  the  enveloping  a})oneun»sis. 
and  as  they  fonii  a  group  differing  from  the  other  only  in 
size,  the  artery  may  be'  mistaken  for  the  brachial  if  met 
with  (Fiof.  42).  This  error  will  not  be  made  if  the  fibres 
of  the  biceps  alone  are  exposetl.  and  the  incision  confined 
to  the  anterior  loge. 

Operation. — Arm  abducted,  forearm  supin.ited.  Make 
an  incision  three  inches  long  in  the  middle  tliird  of  the  ami, 
along  the  inner  border  of  the  biceps  through  the  skin  and 
subcutaneous  cellular  tissue,  taking  care  not  to  injure  the 

Fig.  J3. 


Ligature  of  brachial  artery. 

basilic  vein,  which  should  be  kept  posterior  to  the  incision. 
Divide  the  aponeurosis  and  expose  the  fibres  of  the  biceps. 
If  the  muscle  is  large  draw  it  forward,  and  the  sheath  in- 
closing the  artery,  nerve,  and  veins  will  be  disclo.«ed.  This 
is  torn  through  carefully  with  a  director,  the  median  nerve 
separateil  and  pushed  aside,  the  artery  separated  fi'om  its 
veins,  and  the  ligature  passed  fi'om  the  side  of  the  nerve. 


LIGATURE  OF  THE  RADIAL  ARTERY. 


Anatomy. — The  radial  artery  extends 


from  a  point  half  an  inch  below  the  c^tYt  of  th|  toM  «jfhf 
elbow  to  the  ulnar  side  of  the  styloid  iyroc^»rf^ft^*»<iius ; 


fj^' 


68 


LIGATURE    OF    THE    ARTEJIIES. 


Fig.  44. 


it  occupies  the  groove  bounded  on  one  side  by  the  supinator 
longus,  on  the  other  by  the  pronator  radii  teres  and  flexor 

carpi  radiahs.  It  is  covered  only 
by  the  skin,  cellular  tissue,  and 
aponeurosis;  but  in  muscular  sub- 
jects the  muscular  interstice  in  which 
it  lies  may  be  very  deep.  It  is  ac- 
companied by  two  veins,  and  by  no 
nerve.  It  occupies  in  its  upper 
third  the  sheath  of  the  pronator, 
and  consequently  the  fibres"  of  the 
supinator  longus  should  not  be  ex- 
posed in  the  search  for  the  artery, 
although  the  edge  of  the  muscle 
may  be  taken  as  a  guide  to  it. 
The  radial  nerve  lies  within  the 
sheath  of  the  supinator  longus,  and 
at  first  comes  quite  close  to  the  ar- 
tery ;  it  then  passes  behind  and  to 
the  outer  side  of  the  tendon  of  the 
muscle.  It  should  not  be  seen  dur- 
ing the  operation. 

Operation.  In  the  upper  third. — 
Make  an  incision  two  and  one-half 
inches  long  in  the  line  above  men- 
tioned, beginning  one  and  one-half 
inches  below  the  fold  of  the  elbow. 
Avoiding  the  superficial  veins,  carry 
the  incision  through  the  cellular  tis- 
Recocrnize   the   edsi-e   of    the 


sue. 


Ligature  of  the  radial  aud  ulnar 
arteries. 


supinator 


longus. 


and  divide  the 
aponeurosis  along  the  ulnar  side  of 
it,  exposing  the  fibres  of  the  pronator.  Press  apart  the  two 
muscles  if  necessary,  separate  the  artery  from  its  veins,  and 
pass  the  ligature. 

In  the  loioer  third  (Fig.  44). — Make  an  incision  in  the 
above-mentioned  line,  if  the  position  of  the  artery  cannot  be 
made  out  by  its  pulsations,  two  inches  long,  ending  an  inch 
a])ove  the  wrist.  Divide  the  skin  and  cellular  tissue,  and 
then  the  fascia  carefully  upon  a  director.  Separate  the 
artery  from  the  two  veins,  and  pass  the  ligature. 


LIGATURE    OF    THE    ULNAR    ARTERY.  69 


LUiATURE  (»F  TUE   LEX. Ml   AKTERV. 

Anatomy. — In  its  first  third  tlie  ulnar  artery  passes  ob- 
li(iuely  iiiiderneatli  the  superficial  layer  of  miiscles,  includiiiL' 
the  superficial  fiexor  of  the  fiuirers,  to  the  inner  side  of  ihe 
arm,  where  it  becomes  superficial,  and  lies  between  the 
fiexor  carpi  ulnaris  on  the  inside  and  the  flexor  sublimis 
di^itorum  on  the  outsi<le^  It  then  descends  to  the  wrist  in 
the  direction  of  a  line  uniting  the  internal  condyle  of  the 
humerus  with  the  outer  border  of  the  pisiform  bone.  It  is 
accompanied  by  two  veins,  and  is  joine<l  by  the  ulnar  nerve 
just  before  it  Ijecomes  superficial,  the  nerve  lying  ujjon  the 
inner  or  ulnar  side  of  the  artery.  It  may  be  tied  at  any 
point  in  the  middle  and  lower  thirds.  As  the  deep  and 
superficial  flexors  of  the  fingers  are  separated  by  a  fascia, 
and  as  the  artery  lies  below  this  fascia,  it  is  covered  in  the 
lower  part  of  its  course  by  two  distinct  fasciae,  the  envelop- 
inor  fascia  of  the  limb  and  this  second  one  which  unites  the 
tendon  of  the  flexor  carpi  ulnaris  with  those  of  the  flexoi-s. 

Operation.  At  the  junction  of  the  upper  and  middle 
thirds. — Bednnintr  four  finojer-breadths  below  the  internal 
condyle  of  the  humerus  make  an  incision  three  and  one-half 
or  four  inches  long  in  the  line  above  mentioned  (Fig.  -14). 
Expose  the  enveloping  fascia  clearly,  and,  drawing  back 
the  posterior  lip  of  the  wound,  seek  the  first  muscular  inter- 
stice in  front  of  the  ulna.  It  is  that  between  the  flexor 
carpi  ulnaris  and  the  flexor  sublimis  digitorum,  and  can  be 
recognized  by  the  finger  as  a  slight  depression,  or  by  the 
eye  as  a  white  line  under  the  fascia.  Divide  the  aponeu- 
rosis, beginning  at  the  lower  angle  where  the  space  between 
the  muscles  is  broadest,  and  then,  instead  of  following  the 
interstice  directly  backward,  raise  the  flexor  sublimis  and 
advance  transversely  across  the  arm  in  the  search  for  the 
artery  which  lies  upon  the  deep  flexor.  Isolate  the  artery, 
and  pass  the  needle  frorii  the  side  of  the  nerve. 

In  the  lower  third  (Fig.  -44). — Make  an  incision  slightly 
to  the  radial  side  of  the  tendon  of  the  flexor  carpi  ulnaris, 
or  in  the  line  before  mentioned,  two  inches  long,  and  ending 
an  inch  above  the  end  of  the  ulna.  Divide  the  enveloping 
fascia  upon  a  director,  and  tear  through  the  second  over 


70 


LIGATURE    OF    THE    ARTERIES. 


the  vessel,  wliicli  can  be  seen  and  felt  through  it.  Isolate 
the  artery,  and  pass  the  needle  from  within  outward  so  as 
to  avoid  the  nerve. 


LIGATURE  OF  THE  COMMON  CAROTID. 

The  place  of  election  for  ligature  of  the  common  carotid 
is  just  above  the  omo-hjoid  muscle,  but  the  lesion  which 
renders  the  ligature  necessary  may  require  it  to  be  applied  at 
a  much  lower  point.  The  vessel  has  been  tied  successfully 
at  a  point  one-eighth  of  an  inch  from  its  origin  at  the  bifur- 
cation of  the  innominata. 

The  steps  necessary  to  place  a  ligature  upon  the  common 
carotid  in  the  first  part  of  its  course  are  the  same  as  for 


Fig.  45. 


Ligature  of  the  common  carotid  at  the  place  of  election. 

ligature  of  the  first  portion  of  the  subclavian  or  of  the  inno- 
minata {q.  v.).  After  the  vessel  has  been  exposed,  the 
internal  jugular  is  ])ressed  to  the  outer  side,  the  artery 
denuded,  and  the  needle  passed  from  the  side  of  the  vein. 

At  the  F  J  ace  of  Eh'rtion. — The  bifurcation  of  the  com- 
mon carotid  is  on  a  line  with  the  upper  border  of  the  thy- 


LIGATURE    OF    THE    EXTERNAL    CAROTID.      71 

roid  ("irtihiiic.  Tlic  ])la('e  ol"  election  for  tviiiir  it  is  .-ilxmt 
three-quarters  of  an  incli  below  its  bil'iircation.  Tlic  f^uide 
to  tlie  artery  is  the  anterior  border  of  the  sterno-eleido- 
niastoid  nuisele,  and  the  danger  is  of  wounding  the  jugular 
vein,  wliieh,  when  full,  entirely  covers  the  artery  on  the 
outer  side. 

Oprration. — ]\Iake  along  the  anterior  border  of  the  sterno« 
cleido-niastoid  an  incision  three  inches  in  length,  the  centre 
of  which  corresponds  wifh  the  crico-thyroid  space  (Fig.  45). 
Divide  the  skin,  platysma,  cellular  tissue,  and  aponeurosis, 
and  seek  for  the  interstice  between  the  sterno-cleido-mastoid 
and  the  sub-hyoi<l  muscles.  When  found,  the  latter  must  be 
pressed  inward,  and  the  artery  will  a])pear  at  the  edge  of 
the  sterno-cleido-mastoid,  the  vein,  which  is  external  to  it, 
remaining  covered.  The  artery  is  bared  with  a  director, 
and  the  needle  passed  from  without  inward. 

If,  instead  of  pressing  the  trachea  and  its  muscles  in- 
ward, the  mastoid  is  drawn  outward,  the  vein  is  exposed, 
almost  completely  overlying  the  artery,  and,  by  its  pres- 
ence and  the  necessity  of  handling  it,  increases  the  diffi- 
culty and  danger  of  the  operation. 


LIGATURE  OF  THE  EXTERNAL  CAROTID. 

The  free  anastomoses  which  exist  within  the  cranium 
between  the  two  internal  carotids  render  ligature  of  the 
common  carotid  insufficient  to  arrest  hemorrhage  from  the 
external  carotid ;  the  ligature  must  be  applied  to  the  vessel 
itself,  despite  the  number  of  its  branches  and  the  difficulty 
of  recognizing  them  at  the  bottom  of  the  incision.  The  ope- 
ration is  a  difficult  one,  for  there  are  many  important  organs 
to  be  avoided,  and  there  is  no  direct  guide  to  the  vessel. 

Anatomy. — The  common  carotid  divides  opposite  the 
upper  border  of  the  thyroid  cartilage  (a  little  lower  in 
females)  into  the  external  and  internal  carotids,  which 
occupy  nearly  the  same  antero-posterior  plane,  the  former 
being  in  front.  At  about  three-quarters  of  an  inch  above 
the  bifurcation  the  arteries  cross,  the  external  becoming 
posterior,  the  internal  anterior.  The  internal  carotid  gives 
oft"  no  branches    outside   tlie  cranium,  while   the  external 


72  LIGATURE    OF    THE    ARTERIES. 

gives  off  eight.  Of  tliese  the  superior  thyroid  arises  at  or 
very  near  the  bifurcation,  the  lingual,  fascial,  ascending 
pharyngeal,  and  occipital  near  the  point  where  the  artery 
passes  under  the  digastric,  about  an  inch  above  the  bifurca- 
tion, the  others  at  a  considerable  distance  above.  The 
hypoglossal  nerve  looping  around  the  occipital  artery  at  its 
origin  crosses  the  external  carotid  to  the  hyoid  bone,  send- 
ing a  branch,  the  descendeyis  no7ii,  down  the  outside  of  the 
artery. 

There  are  thus  three  means  of  distinguishing  the  external 
carotid:  1,  its  branches;  2,  its  position  with  reference  to 
the  internal  carotid;  3,  its  immediate  relations  with  the 
hypoglossal  nerve,  the  internal  carotid  occupying  a  deeper 
plane.  In  a  search  for  the  external  carotid  the  ojierator 
may  be  satisfied  with  either  of  these  guides,  accordingly  as 
one  or  the  other  presents  itself.  Should  the  nerve  be  first 
encountered,  he  will  tie  the  vessel  upon  which  it  lies;  should 
both  vessels  lie  at  the  bottom  of  the  incision,  he  will  know 
that  the  anterior  one  is  the  external  carotid;  and  if  the 
vessel  which  he  isolates  has  a  branch,  he  knows  it  cannot  be 
the  internal  carotid. 

Although  the  force  of  the  objection  has  been  greatly 
diminished  by  the  employment  of  antiseptic  silk  or  catgut 
ligatures,  which  admit  of  primary  union  throughout  the 
wound,  it  is  still  desirable  that  the  ligature  should  be  ap- 
plied at  a  distance  from  branches  of  considerable  size ;  and 
from  this  point  of  view  the  first  half  inch  of  the  artery 
and  the  portion  underlying  the  digastric  are  the  places  of 
election,  and  of  these  two  the  former  alone  is  practicable. 
The  connective  tissue  surroundino;  the  two  arteries  at  their 
origin  is,  however,  unusually  compact,  rendering  their  denu- 
dation so  difficult  that  any  search  for  branches  would  be 
dangerous  to  the  nutrition  of  the  vessel's  wall. 

M.  Cnwon^  has  shoft'n  that,  while  the  lingual  and  superior 
thyroid  arteries  vary  greatly  in  their  points  of  origin,  the 
average  distance  between  them  is  from  12  to  18  millimetres, 
or  over  half  an  inch  ;  he  calls  the  portion  of  the  vessel  be- 
tween them  the  "'trunk  of  the  external  carotid,'  and  sug- 
gests that  the  ligature  should  be  applied  G  mm.  below  the 

'  Memoires  de  la  Soc.  de  Chirurgie,  18G4,  p.  o55. 


LIGATURE    OF    THE    EXTERNAL    CAROTTl) 


73 


point  ill  wliicli  tlic  livpof^lossal  ium-vc  crosses  the  Mi-tcry,  tliis 
iK'i've  l)oiii^,  ill  tlic  groat  iiuijority  of  cases,  in  iinnictljate 
relation  with  tlie  origin  of  tlie  lingual  artery.  Dolheau,  in 
liis  report  upon  this  paj)cr,  advises  that  the  superior  thyroid 
shoidd  also  be  tied,  and  tliat  tlie  carotid  should  be  sought 
for  from  below  upward  instead  of  from  above  downward, 
on  account  of  the  greater  depth  of  its  u})per  portion  and 
the  superj)osition  of  large  veins.  M.  (iuyon  collected  24 
cases  of  ligature  of  the'  external  carotid  without  especial 
reference  to  the  proximity  of  branches,  and  in  only  one  of 
them  did  secondary  hemorrhage  occur. 

Operation. — When    the  head  is  extended   and   the  face 
turned  to  tlie  opposite  side,  an    incision  carried  from  the 

Fig.  40. 


Ligature  of — A.  Lingual  arterj',     B.  External  carotid.     C.  Occipital. 
D.  Temporal.     E.  Facial. 

angle  of  the  jaw  to  the  anterior  border  of  the  sterno-cleido- 
mastoid  opposite  the  top  of  the  thyroid  cartilage  w^ill  cross 
the  artery  o])li(|uely  (Fig.  46,  B).  It  must  be  carried 
through  the  skin,  platysma,  and  subcutaneous  cellular  tissue, 

7 


74  LIGATURE    OF    THE    ARTERIES. 

tlie  external  juuular  being  drawn  aside  when  encountered. 
The  superiicial  fascia  is  then  divided  in  the  line  of  the  in- 
cision, care  being  taken  not  to  deviate  to  the  right  or  left, 
and  the  deeper  and  denser  layer  then  torn  through  with  the 
director.  When  the  artery  has  been  exposed  and  cleaned, 
the  needle  is  passed  from  behind  forward. 

The  lymphatic  glands  of  the  region  are  numerous  and 
often  large,  and  may  be  mistaken  for  the  artery.  There  is 
no  ol)jection  to  removing  any  that  may  interfere  with  the 
search  for  the  vessel. 


LK^ATURE  OF  THE  IXTERXAL  CAROTID. 

This  is  to  be  done  according-  to  the  method  described  for 
the  external  carotid. 

LIGATURE  OF  THE  LIXGUAL  ARTERY. 

Anatomy. — The  lingual  artery  arises  from  the  external 
carotid,  on  a  level  with  the  great  horn  of  the  liyoid  bone, 
and  passes  between  the  middle  constrictor  of  the  pharynx 
and  the  hyoglossus  upward  and  forward.  It  is  occasion- 
ally accompanied  by  a  small  vein,  but  the  lingual  vein  is 
separated  from  it  by  the  thickness  of  the  hyoglossus  mus- 
cle. Its  one  important  branch,  the  sublingual,  sometimes 
has  its  oricrin  at  or  near  the  point  where  the  Unequal  is 
usually  tied,  and  may  be  mistaken  for  it.  The  artery  may 
be  tied  near  its  origin,  between  the  great  horn  of  the  hyoid 
bone  and  the  posterior  belly  of  the  digastric,  but  its  depth 
at  this  point,  and  the  presence  of  large  veins,  make  the 
operation  difficult  and  dangerous.  The  place  of  election  is 
in  the  triangle  bounded  posteriorly  by  the  posterior  belly 
of  the  digastric,  anteriorly  by  the  posterior  border  of  the 
mylo-hyoid,  and  above  by  the  hypoglossal  nerve.  It  is 
covered  at  this  point  by  the  skin,  platysma,  cervical  aponeu- 
rosis, submaxillary  gland,  and  the  hyoglossus  muscle,  the 
fibres  of  which  form  the  floor  of  the  triangle  just  described. 

Operation. — Make  a  curved  incision  two  inches  long,  its 
concavity  directed  upward,  its  centre  one-quarter  of  an 
inch  above  the  hyoid  bone  at  a  point  midway  between  the 


LIGATTHK    OK    THK    F  A  (^  I  A  L    ARTERY, 


75 


me<lian  line  ami  the  extremity  of  the  great  liorn  (Fig.  46, 
A).  Divide  the  skin  and  phitysnia,  pushing  the  super- 
ficial veins  aside,  and  tlien  the  cervical  a])(>neurosis,  which 
may  be  very  tliin.  Raise  tlie  submaxillary  ghmd,  find  tlic 
posterior  belly  of  the  digastric,  its  attachment  to  the  hyoid 
bone,  the  posterior  border  of  the  mylo-hyoid,  and  the  hypo- 
glossal nerve  accompanied  by  the  lingual  vein.     Draw  the 


'   Fia.  47. 

r>_  Pucial  Veiv 

'lllllr^     ■  /      Facial  Art. 


Ilyo^lossHS 


JMylo-hyoid 
Digastric 
Us  Ilyoidts 

Anatomical  relations  of  the  lingual  and  facial  arteries.     (Tillaux.) 

hyoid  bone  slightly  downward  with  a  blunt  hook  fixed  in 
the  lower  angle  of  the  triangle  bounded  by  these  organs, 
and  then,  pinching  up  the  fibres  of  the  hyoglossus  with  a 
pair  of  forceps,  divide  them  carefully  along  a  line  parallel 
to  the  nerve,  and  midway  between  it  and  the  bone.  As  the 
cut  fibres  retract,  the  artery  is  disclosed  below  them  ;  sepa- 
rate it  from  its  vein,  if  there  be  one,  and  pass  the  ligature. 


LK4ATURE  OF  THE    FACIAL  ARTERY. 

The  facial  artery  crosses  the  inferior  maxilla  just  in  front 
of  the  anterior  edge  of  the  masseter,  from  which  it  is  sepa- 


76  LIGATURE    OF    THE    ARTERIES. 

rated  by  the  facial  vein  (Fig.  47).  A  depression,  in  which 
it  is  lodged,  can  usually  be  felt  on  the  lower  edge  of  the 
bone.  The  artery  can  be  exposed  by  a  vertical  incision 
along  its  course,  or  by  a  horizontal  one  along  the  lower 
border  of  the  maxilla. 

Operation  (Fig.  4(3,  E). — Beginning  at  the  lower  edge 
of  the  maxilla  make  an  incision  one  inch  in  length  along  the 
course  of  the  artery ;  divide  the  skin,  subcutaneous  tissue, 
and  fascia ;  separate  the  artery  from  the  vein  and  pass  the 
needle  between  them. 

If  the  horizontal  incision  is  used,  it  should  extend  three- 
quarters  of  an  inch  on  each  side  of  the  artery,  the  anterior 
edge  of  the  masseter  should  be  recognized,  and  the  vessel 
sought  for  immediately  in  front  of  it. 

LIGATURE  OF  THE  OCCIPITAL  ARTERY. 

At  the  Mastoid  Process. — The  guides  to  the  vessel  are  the 
apex  and  posterior  border  of  the  mastoid  process,  the  digas- 
tric groove  on  its  inner  surface,  and  the  digastric  muscle. 

Operation  (Fig.  46,  C). — Starting  from  a  point  half  an 
inch  below  and  in  front  of  the  apex  of  the  mastoid  process, 
carry  the  incision  two  inches  obliquely  backward  parallel  to 
the  border  of  this  process.  Divide  the  skin  and  enveloping 
fascia,  and  then  the  sterno-mastoid  and  its  insertion  through- 
out the  entire  length  of  the  incision.  Then  divide  the 
splenius  and  its  shining  aponeurosis,  and  feel  for  the  digas- 
tric groove.  Pinch  up  and  carefully  divide  a  thin  fascia 
which  covers  the  anterior  face  of  the  splenius.  Starting 
from  the  belly  of  the  digastric,  separate  the  cellular  tissue  in 
the  anterior  angle  of  the  wound  with  a  director,  denude  the 
artery  and  tie.  {Ohauvel.) 

LIGATURE  OF  THE  TEMPORAL  ARTERY. 

(Fig.  46,  D.) — Make  a  transverse  incision  one  inch  long, 
extending  from  the  tragus  of  the  ear  forward  over  the 
zygomatic  arch.  Separate  the  subcutaneous  cellular  tissue, 
which  is  very  dense  and  fibrous,  with  a  director,  and  seek 
the  artery  embedded  in  it  about  a  quarter  of  an  inch  in  front 


LIGATURE    OF    THE    COMMON    ILIAC.  77 

of  tlie  ear.  Press  the  vein  backward,  j)ass  the  needle  from 
beliind  forward,  takinLT  eare  not  to  include  in  the  li<Mtin-c 
the  temporal  branch  of  the  auriculo-temj)oral  nerve,  which 
is  sometimes  in  close  relations  with  the  artery. 

LIGATURE  OF  THE  ABDOMINAL  AORTA. 

This  operation  has  b^en  performed  eight  times,  with  a 
fatal  result  in  each  case.  The  patients  survived  for  periods 
varyin<r  from  a  few  hours  to  ten  days.  The  artery  may  be 
reached  through  the  abdominal  cavity  by  an  incision  in  the 
median  line,  or,  without  dividing  the  peritoneum,  by  an  in- 
cision in  the  flank.  The  objection  to  the  former  is  the 
danger  conse([uent  upon  exposure  of  the  peritoneal  sac  and 
its  contents,  but  the  steadily  impi-oving  results  of  abdominal 
surgery  show  that  this  is  not  exceptionally  great.  On  the 
other  hand,  the  application  of  a  ligature,  even  under  the 
most  favorable  circumstances,  after  the  artery  has  been  ex- 
posed by  the  other  method,  requires  the  utmost  dexterity, 
the  chance  of  exciting  peritonitis  is  great,  and,  finally,  the 
presence  of  the  aneurism  and  the  displacements  and  adhe- 
sions it  has  caused  may  render  it  impossible  to  reach  the 
vessel. 

Operation.  Through  the  Peritoneal  Cavity. — An  in- 
cision in  the  linea  alba,  extending  from  a  point  three 
inches  above  the  umbilicus  to  one  three  inches  below  it,  and 
curving  to  one  side  to  avoid  the  umbilicus.  Divide  the 
peritoneum  upon  a  director,  press  the  intestines  aside,  tear 
through  the  peritoneum  covering  the  aorta  with  the  finger- 
nail, separate  the  nerves  from  its  anterior  surface,  and  pass 
the  ligature  from  the  outer  side.  Cut  both  ends  short,  and 
close  the  external  wound  as  in  ovariotomy. 

LIGATURE  OF  THE  COMMON  ILIAC. 

Aiiatomif  of  the  Common,  Internal.,  and  External  Iliac 
Arteries. — The  aorta  bifurcates  usually  on  the  left  side  of 
the  fourth  luml)ar  vertebra,  and  the  direction  of  the  com- 
mon and  external  iliacs  is  represented  by  a  line  drawn  from 
a  point  an  inch  above  the  umbilicus  to  another  one-half  an 

7* 


78  LIGATURE    OF    THE    ARTERIES. 

inch  external  to  the  centre  of  Poupart's  ligament.  The 
common  iliac  is  usually  two  inches  long,  and  bifurcates  at 
the  sacro-iliac  synchoncb-osis.  but  it  must  be  remembered  that 
this  bifurcation  may  take  place  at  any  point  between  one  and 
a  half  and  three  or  even  four  inches  from  the  origin  of  the 
artery.     The  common  iliac  gives  off  no  branches. 

The  external  iliac  nins  downward  and  outward  along 
the  brim  of  the  pelvis  from  the  bifurcation  to  a  point  under 
Poupart's  ligament  midway  between  the  anterior  superior 
spine  of  the  ilium  and  the  symphysis  pubis.  Its  two 
branches,  the  epigastric  and  circumflex  ilii,  are  given  off 
nearly  opposite  each  other,  a  short  distance  above  Poupart's 
licrament,  sometimes  much  hicrher. 

The  internal  iliac  runs  downward  and  backward  inti)  the 
pelvis  for  one  and  a  half  inches,  dividing  at  the  upper  border 
of  the  great  sacro-sciatic  foramen  into  two  large  trunks. 
The  ureter  crosses  the  vessels  at  or  just  below  the  bifurcation 
of  the  common  iliac,  the  vas  deferens  two  and  a  half  or  three 
inches  lower.  Both  are  more  closely  adherent  to  the  peri- 
toneum than  to  the  arteries.  The  iliac  veins  lie  upon  the 
inner  side  and  posterior  to  the  arteries;  both  pass  behind 
the  right  common  iliac,  the  right  vein  at  its  bifurcation,  the 
left  vein  much  higher  up.  The  speiTaatic  vessels  and  genito- 
crural  nerve  lie  in  front  of  the  external  iliac  at  the  lower 
part  of  its  course,  and  the  circumflex  iliac  vein  crosses  it  at 
the  same  place. 

The  abdominal  wall  at  the  point  where  the  incisions  are 
made  is  composed  of  the  following  layers  in  the  order 
named:  skin,  subcutaneous  cellular  tissue,  fascia,  external 
oblique  or  its  aponeurosis,  internal  oblique,  transversalis, 
and  transversalis  fascia. 

Operation. — Beginning  at  a  point  a  finger's  breadth 
above  Pouparts  ligament  and  just  outside  of  the  external 
iliac  artery,  make  an  incision  four,  five,  or  six  inches  in 
length,  according  to  the  thickness  of  the  abdominal  wall, 
parallel  at  first  to  Poupart's  ligament,  and  curving  upAvard 
after  passing  the  anterior  superior  spine  of  the  ilium  (Fig. 
48j.  Divide  the  skin,  subcutaneous  tissue,  and  fascia, 
exposing  the  aponeurosis  of  the  external  oblicpie  :  divide  the 
latter  upon  a  director  throughout  the  whole  extent  of  the 
incision,  and  then  divide  the  fibres  of  the  internal  oblique 


LIGATURE    OF    THE    COMMON    ILIAC. 


79 


and  transvcrsalis  in  the  same  manner,  or  )»v  i»incliin<r  tliem 
up  Avitli  the  forceps  and  cuttin«^  carefully  with  repeated 
sli<rht  touches  of  the  knife,  until  the  fascia  transvcrsalis, 
which  varies  much  in  density,  is  exposed.  Kaise  the  fascia 
at  the  lower  angle  of  the  wound,  where  it  is  most  dense, 


Fig.  48. 


Ligature  of  :   A,  Common  iliac  ;  B,  External  iliac  ;  C,  Femoral  in  Scarpa's  space. 

with  forceps,  and  make  a  hole  in  it  large  enough  to  admit 
the  finger.  Pass  the  forefinger  through  this  hole,  press 
back  the  peritoneum  with  it.  and  enlarge  the  hole  upward 
in  the  line  and  to  the  full  extent  of  the  incision,  the  finger 
being  kept  between  the  peritoneum  and  the  knife. 

The  peritoneum  is  now  raised  fi'om  the  psoas  and  iliacus 
muscles  and  drawn  upward  and  inward  by  an  assistant, 
while  the  operator  seeks  for  the  external  iliac  and  passes 
the  forefinger  of  his  left  hand  along  it  to  the  common  iliac, 
the  thighs  being  flexed  to  relax  the  abdominal  walls.  As 
it  is  seldom  that  a  good  view  of  the  artery  can  be  obtained, 
the  finger  must  be  kept  upon  it,  and  the  loose  cellular  tissue 
in  which  it  is  embedded  very  gently  separated  with  the 
point  of  a  director  or  the  finger-nail.     "When   the  artery 


80  LIGATURE    OF    THE    ARTERIES. 

has  been  j^roperly  cleaned,  pass  tlie  needle  from  within 
outwards. 

Thr  operation  through  the  peritoneal  cavity^  as  for  liga- 
ture of  the  abdominal  aorta,  has  recently  been  done  with  suc- 
cess, and  will  probably  be  preferred  to  the  extra-peritoneal 
method. 

LIGATURE  OF  THE  INTERNAL  ILIAC. 

Its  accompanying  vein  lies  behind  and  on  the  inner  side. 

Operation, — Same  as  for  ligature  of  the  common  iliac. 
After  the  peritoneum  has  been  lifted  up,  the  finger  is  passed 
alonor  the  external  iliac  to  the  bifurcation,  and  then  down- 

O  ... 

ward  for  half  an  inch  along  the  internal  iliac.  The  vein 
being  carefully  protected,  the  artery  is  bared,  and  the  liga- 
ture passed  from  within  outAvard. 

Ligature  of  the  internal  iliac  has  been  seldom  employed, 
except  for  traumatic  gluteal  aneurism,  and  in  these  cases, 
as  Professor  Van  Buren^  has  pointed  out,  the  treatment 
should  be  to  cut  down  upon  the  sac,  and  tie  both  ends  of  the 
artery,  hemorrhage  being  controlled  by  digital  pressure 
made  upon  the  internal  iliac  from  within  the  rectum. 

LKiATURE  OF  THE  EXTERXAL  ILIAC. 

Various  cutaneous  incisions  have  been  recommended  for 
this  operation.  Sir  Astley  Cooper's  extended  from  the 
external  abdominal  ring  to  within  a  short  distance  of  the 
superior  spine  of  the  ilium;  the  objections  to  it  are  that  it 
involves  the  division  of  the  superficial  epigastric,  and,  per- 
haps, of  the  internal  epigastric  also,  and  that  the  hgature 
can  be  applied  only  to  the  lower  part  of  the  artery.  Aber- 
nethv's  extended  outward  from  the  internal  incruinal  rino; 
parallel  to  Poupart's  ligament;  by  it  the  vessel  is  reached 
at  a  greater  depth,  but  it  has  the  great  advantage  of  allow- 
ing extension,  so  that  if  it  should  prove  necessary  the  liga- 
ture may  be  applied  even  to  the  common  iliac.  By  curving 
the  outer  portion  of  the  incision  upward  away  from  the 
superior  spine  of  the  ilium,  the  main  branches  of  the  cir- 
cumflex ilii  may  be  avoided. 

^  Report  on  Aneurism ;  Proceedings  of  the  International  Medical 
Congress,     187G. 


GLUTEAL,  SCIATIC,  AND    INTERNAL    PUDIC.      81 

O/nratf'on. — I>('iriiinini»;  over  tlic  outer  side  of  tlic  urtery 
a  fiii<^or's  breadth  above  I'oiipart'.s  ligament,  make  an  in- 
cision tliree  or  four  inches  in  lengtli,  at  first  parallel  with 
Poupart's  li<j:ament,  and  then  curving  upward  (Fig.  48). 
Carry  this  incision  through  the  abdominal  wall,  and  raise 
the  peritoneum  from  the  surface  of  the  iliacus  and  psoas 
muscles  in  the  same  manner  as  for  ligature  of  the  common 
iliac.  Flex  the  thighs  so  as  to  relax  the  abdominal  muscles, 
and,  while  an  assistant  draws  the  peritoneum  and  the  con- 
tained intestines  upward  and  inward,  seek  the  artery  upon 
the  inner  border  of  the  psoas.  Clean  it  with  a  director  or 
pair  of  forceps,  and  pass  the  needle  from  within  outward. 


LIOATURE  OF  THE   GLUTEAL,  SCIATIC,  AND  INTERNAL   PUDIC 

ARTERIES. 

The  proper  treatment  of  injury  to  either  of  these  arteries 
is  to  enlarge  the  wound  and  tie  both  ends  of  the  divided 


Fig.  49. 


Ligature  of:  A.  Gluteal  artery.     B.  Sciatic  and  internal  pudic. 

vessel,  but  it  may  happen  that  this  would  be  impossible,  and 
that  ligature  in  continuity  is  required.     The  necessary  in- 


82  LIGATURE    OF    THE    ARTERIES. 

cisions  are  those  shown  in  Fig.  49.  After  division  of  the 
skin  and  f\iscia,  the  fibres  of  tlie  gluteus  maximus  are  sepa- 
rated, and  hehl  apart  Avith  long  retractors,  the  deep  faseia 
torn  through,  and  the  artery  sought  for. 

The  gluteal  artery  is  to  be  sought  for  above  the  pyri- 
formis  muscle  at  the  upper  border  of  the  great  sacro-sciatic 
notch,  where  it  can  be  felt  near  a  small  bony  tubercle.  It 
is  covered  by  many  large  veins,  which  require  very  careful 
handling.  The  ligature  should  be  applied  as  close  to  the 
notch  as  possible. 

The  sciatic  and  internal  pudic  arteries  leave  the  great 
sciatic  notch  at  the  lower  edge  of  the  pyriformis ;  the  former 
divides  almost  immediately,  the  latter  reenters  the  pelvis 
tlirough  the  lesser  sacro-sciatic  notch,  lying  on  the  inner 
side  of  the  sciatic  artery  during  its  passage  over  the  spine 
of  the  ischium. 


LIGATURE  OF  THE  FEMORAL  ARTERY. 

Anatomy. — The  femoral  artery  is  the  continuation  of  the 
external  iliac,  and  extends  in  a  straight  line  from  a  point 
midway  between  the  anterior  superior  spine  of  the  ilium, 
and  the  symphysis  pubis  to  the  ring  in  the  tendon  of  the 
adductor  maornus  about  four  fincrer-breadths  above  the  tuber- 
cle  of  insertion  of  that  muscle  on  the  upper  portion  of  the 
inner  condyle  of  the  femur.  In  the  first  one  or  two  inches 
of  its  course  it  gives  ofi"  the  superficial  external  pudic,  epi- 
gastric, and  circumflex  ilii,  and  the  much  larger  and  more 
important  profunda  arteries.  The  anastomotica  magna  arises 
near  its  lower  end.  The  artery  is  accompanied  throughout 
by  the  femoral  vein,  which,  at  first,  lies  upon  the  inner  side, 
and  then  becomes  posterior.  They  are  separated  at  first 
by  a  distinct  septum,  which  disappears  in  the  low^er  third. 
The  anterior  crural  nerve  emerges  from  below  Poupart's 
ligament,  about  half  an  inch  external  to  the  artery;  it 
divides  up  rapidly,  and  one  of  its  brandies,  the  internal  or 
Ions  sa])henous,  enters  the  sheath  of  the  vessels  three  or 
four  inches  below^  the  groin,  and  leaves  it  again  after  the 
artery  has  entered  Hunter's  canal ;  this  name  being  given 
to  the  condensed  sheath  for  a  short  distance  above  and  be- 


LIGATURE    OF    THE    FEMORAL    ARTERY 


83 


low  the  j)oiiit  where  it  passes  tlirougli  tlie  tendon  of  the 
adductor  maii;niis.  The  artery  passes  under  the  sartorius 
at  ahout  tlie  junction  of  its  upper  and  ini(hlle  thirds. 

Ligature  of  the  femoral  ahove  the  origin  of  the  pnjfunda 
has  proved  unsatisfactory,  and  has  been  generally  aljan- 
doned  for  that  of  the  external  iliac.  The  ai-tery  may  be 
tied  at  any  part  of  its  course,  but  the  point  generally  chosen 
is  at  the  apex  of  Scarpa's  triangle,  next  that  in  the  middle 
of  the  thigh,  and,  lastly,  in  Hunter's  canal. 

Openition.  A.  At  the  Apex  of  Scarp<i's  Trian(jJe  (Figs. 
48  and  50). — Make  an  incision  three  or  four  inches  long, 


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the  centre  of  which  shall  be  a  little  above  tlie  point  where 
the  inner  border  of  the  sartorius  crosses  a  line  drawn  from 
the  middle  of  Poupart's  ligament  to  the  inner  tuberosity  of 
the  femur.  The  internal  saphenous  vein  should  be  out  of 
danger  on  the  inner  side  of  the  incision.  Divide  the  skin, 
subcutaneous  tissue,  and  the  fascia  lata,  exposing  the  fibres 
of  the  sartorius,  which  may  be  recognized  by  their  direction 
downward  and  inward,  those  of  the  adductors,  on  the  con- 
trary, being  downward  and  outward.  The  limb  should  now 
be  slightly  flexed,  the  vessels  recognized  by  the  touch  at  the 
inner  border  of  the  sartorius,  this  muscle  drawn  outward, 
and  the  sheath  of  the  vessels  pinched  up  with  forceps  on  the 
outer  side  (the  vein  lying  on  tlie  inner)  and  opened.  Bell 
recommends  that  one  edge  of  the  incision  in  the  sheath 
should  be  grasped  with  a  pair  of  spring  forceps  and  confided 


84  LIGATURE    OF    THE    ARTERIES. 

to  an  assistant,  while  tlie  operator  himself  holds  the  other, 
and  carefully  denudes  the  artery  with  a  sharp  knife  to  a 
very  limited  extent.  He  thinks  the  danger  of  injury  to  the 
vein  less  than  that  of  failure  in  consequence  of  the  rupture 
of  too  many  of  the  vasa  vasorum.  The  needle  is  then  passed 
from  within  outward. 

B.  In  the  Middle  of  the  Thhjh. — Here  the  vessel  lies 
underneath  the  sartorius  which  overlaps  it  on  both  sides. 
The  incision  is  made  in  the  line  above  mentioned,  its  centre 
being  a  little  above  the  middle  of  the  thigh  ;  the  sartorius 
is  exposed  and  draAvn  outward  after  the  leg  has  been  further 
flexed.  The  vessel  is  then  sought  for,  exposed,  and  tied  as 
before. 

C.  In  Hunter  s  Canal.— Ah^Mci  and  flex  the  thigh,  and 
rotate  it  outward  so  as  to  make  the  adductors  tense  ;  feel 
for  the  tendon  of  the  adductor  magnus  and  make  an  incision 
three  or  four  inches  long,  the  centre  of  which  is  at  the 
junction  of  the  lower  and  middle  thirds  of  the  thigh,  in  the 
direction  of  the  tendon,  which  is  that  of  a  line  drawn  from 
the  spine  of  the  pubis  to  the  tubercle  on  the  inner  condyle 
of  the  femur.  Divide  the  skin  and  subcutaneous  tissue 
carefully  so  as  not  to  wound  the  internal  saphenous  vein,  and 
then  the  aponeurosis  upon  a  director.  Recognize  the  fibres 
of  the  sartorius  and  of  the  vastus  internus  which  are  at 
right  angles  with  one  another,  and  by  pressing  the  former 
inward  or  the  latter  outward  the  tendon  of  the  adductor 
and  the  curved  glistening  fibres  arching  from  it  to  the  vastus 
internus  are  exposed.  If  the  saphenous  nerve  is  now  en- 
countered it  should  be  traced  upward,  a  director  passed  into 
the  orifice  through  which  it  emerges,  and  the  aponeurosis 
divided  upward ;  if  the  nerve  is  not  seen  it  should  not  be 
sought  for,  but  the  aponeurosis  should  be  pinched  up  and 
divided  close  to  the  tendon  of  the  adductor.  The  sheath  of 
the  vessels  is  now  opened,  and  the  artery  separated  from  the 
closely  adherent  vein.  The  needle  should  be  passed  from 
within  outward. 

Some  surgeons  prefer  to  make  the  first  incision  in  the 
direction  of  the  artery  rather  than  in  that  of  the  tendon. 


LIGATURE    OF    THE    ANTERIOR    TIBIAL.         85 


LUiATURE  OF  THE  POPLITEAL  ARTERY. 

Til  is  is  an  o}X'r:ition  wliicli  is  rcn^uiivd  only  in  the  rare 
cases  of  rupture  of  the  artery  wlieii  an  attempt  is  to  be 
made  to  save  tlie  limb.  Tlie  artery  lies  very  deep  between 
the  condyles  of  the  femur,  embedded  in  fat,  and  directly 
covered  by  the  vein,  the  walls  of  which  are  thick  and  stiff 
like  those  of  an  artery.  The  short  saphenous  vein  perforates 
the  fascia  near  the  centre  of  the  popliteal  space,  and  empties 
into  the  main  trunk. 

Operation. — Make  an  incision  three  or  four  inches  long 
in  the  vertical  diameter  of  the  popliteal  space,  the  centre  of 
which  shall  correspond  to  the  point  at  which  the  ligature  is 
to  be  placed.  Divide  the  skin  and  cellular  tissue,  taking 
care  not  to  injure  the  saphenous  vein,  and  then  the  aponeu- 
rosis to  the  full  extent  of  the  cutaneous  incision.  Flex  the 
leg,  have  the  sides  of  the  wound  dmwn  widely  apart,  and 
work  down  through  the  fat  and  lymphatic  glands  to  the 
artery,  leaving  first  the  nerve  and  then  the  vein  upon  the 
outer  side.  Protecting  the  vein  with  one  finger,  denude  the 
artery  and  pass  the  needle  from  without  inward. 

Jobert  (de  Lamballe)  reached  the  popliteal  artery  in  the 
upper  part  of  its  course  by  an  incision  on  the  inner  aspect 
of  the  leg,  passing  between  the  tendon  of  the  adductor  mag- 
nus  on  one  side,  and  the  sartorius,  semi-membranosus,  and 
semi-tendinosus  on  the  other.  The  artery  is  found  lying 
close  to  the  femur. 


LIGATURE  OF  THE  ANTERIOR  TIBIAL  ARTERY. 

Anatomy. — After  perforating  the  interosseous  membrane 
at  the  upper  part  of  the  leg,  the  anterior  tibial  runs  in  a 
direction  which  is  that  of  a  line  drawn  upon  the  anterior 
aspect  of  the  leg  from  the  upper  tibio-fibular  articulation 
to  a  point  midway  between  the  malleoli.  It  lies  at  first 
between  the  belly  of  the  tibialis  anticus  and  that  of  the 
extensor  communis  digitorum  upon  the  interosseous  mem- 
brane, aflerward  between  the  tibialis  anticus  and  the  exten- 
sor proprius  pollicis  or  their  tendons  upon  the  tibia.     It  is 


86 


LIGATURE    OF    THE    ARTERIES. 


accompanied  bv  two  veins  and  the  anterior  tibial  nerve, 
which  lies  first  upon  the  outer  side  and  then  crosses  in  front 
to  the  inner  side.     It  may  be  tied  at  any  point  in  its  course. 


Fig.  51. 


Transverse  section  of  the  leg,  upper  third.  (Tillaux.)  T  Tibia.  F.  Fibula.  EF.  En- 
veloping fascia.  BF.  Deep  fascia  dividing  to  inclose.  PT.  Posterioi*  tibial  artery  .and 
nerve,  and  PA.  Peroneal  artery.  TA  Tibialis  anticus  muscle.  AT.  Anterior  tibial 
artery  and  nerve,  m.  Interos-seous  membrane.  P.  Peroncus  longus  muscle.  IS.  In- 
ternal saphenous  vein.    ES.  External  saphenous  vein  and  nerve. 

Operation. — Make  in  the  above-mentioned  line  an  incision 
the  length  of  which  will  vary  according  to  the  depth  at  which 
the  artery  is  placed.  Divide  the  skin  and  cellular  tissue, 
lay  bare  the  fascia,  and  divide  it  along  the  first  muscular 
interstice,  which  shows  as  a  white  line  under  it;  make  also 
a  transverse  incision  through  the  fascia  from  the  middle  of 


LIGATUJIE    OF    THE    roSTElllOK    TIBIAL 


87 


tlie  longitudinal  one  to  tlie  crost  of  tlic  tibia,  so  as  to  give 

more   room.      Flex    tlie    foot    upon  the    leg,    separate    tlie 

muscles    from    below  upward   with  tlie    finger,   draw  them 

apart   with    retractors,    isolate    the 

artery  -without  raising  it,  and  pass  ^^'"^*-  •^'-• 

the   needle    from    the    side   of  the  i 

nerve.  I        ^^f^i^i^iif^^'       ■ 


LIGATURE  OF  THE  DORSALLS  PEDIS. 

This  artery  is  the  continuation 
of  the  anterior  tibial  and  passes 
through  the  posterior  end  of  the 
first  metatarsal  space  to  the  plantar 
aspect  of  the  foot.  It  lies  on  the 
outer  side  of  the  tendon  of  the 
extensor  proprius  pollicis,  and  is 
crossed  in  its  lower  portion  b}^  the 
inner  tendon  of  the  extensor  brevis. 
It  is  covered  by  the  skin,  superfi- 
cial fascia,  the  edge  of  the  extensor 
brevis  or  its  tendon,  and  a  deep 
fascia.  Its  direction  is  that  of  a 
line  drawn  from  a  point  midway 
between  the  malleoli  to  the  pos- 
terior end  of  the  1st  metatarsal  space.  The  incision 
be  in  this  line,  and  the  tendon  of  the  extensor  propri 
licis  should  be  left  on  the  inner  side. 


Ligature  of  the  anterior  tibial 
artery. 


should 
us  pol- 


LIGATURE  OF  THE  POSTERIOR  TIBIAL. 

The  posterior  tibial  artery  in  its  upper  and  middle  por- 
tions lies  upon  the  tibialis  posticus  and  the  flexor  eonmiunis 
digitorum,  and  is  covered  by  the  soleus,  from  which  it  is 
separated  by  the  deep  fascia.  Near  the  ankle  it  is  covered 
only  by  the  integument  and  fascia.  In  its  upper  portion 
it  can  be  reached  by  two  routes :  1,  the  one  employed  by 
Guthrie,  and  approved  of  by  Spence  and  Holmes,  through 
the  middle  of  the  calf;  2,  the  one  in  more  common  use,  from 
the  inner  side  of  the  calf. 


88 


LIGATURE    OF    THE    ARTERIES, 


Operation.  [Guthrie.) — Beginning  at  the  lower  angle  of 
the  popliteal  space,  make  an  incision  six  inches  in  length 
directly  downward,  avoiding  as  far  as  possible  the  super- 
ficial veins,  carry  this  incision 
through  the  soleus,  divide  the 
deep  fascia,  separate  the  ar- 
tery from  the  vein  and  nerve, 
which  are  superficial  to  it, 
and  pass  the  needle  from  their 
side. 

Lateral  3IetJwd.  —  Begin- 
ning in  the  middle  of  the  up- 
per third  of  the  leg,  make  an 
incision  from  four  to  five 
inches  long,  parallel  to  and 
half  an  inch  behind  the  inner 
border  of  the  tibia.  Carry  the 
incision  down  to  the  fascia, 
leaving  the  external  saphena 
on  the  tibial  side ;  divide  the 
fascia,  draw  the  gastrocnemius 
backward,  and  separate  the 
soleus  at  its  attachment  to  the 
tibia,  leaving  the  deep  fascia 
attached  to  the  bone.  Kaise 
the  heel  and  flex  the  leg  upon 
the  thigh,  draw  back  the  calf, 
enlarge  the  incision  if  neces- 
sary, seek  the  artery  and  tear 
carefully  through  the  deep 
fascia  over  it ;  isolate  the  ar- 
tery, leaving  the  nerve  on  the 
outer  side,  and  pass  the  needle 
between.  Tillaux^  has  proposed 
a  modification.  Instead  of  detachino-  tlie  soleus  from  the 
tibia,  he  passes  between  it  and  the  gastrocnemius,  and  then 
divides  the  former  muscle  longitudinally  over  the  course  of 
the  artery.     If  this  incision   does  not  at  once  expose  the 


Ligature  of  the  posterior  tibial  artery 


^  Anatomie  topograpliique,  Paris.  1877,  p.  114-5. 


LIGATURE    OF    THE     rOSTEKlOH    TllilAL.        89 

artery,  the  vessel  must  he  soii^lit  for  on  one  side  or  tlieotlier 
by  ])ressiiin;  back  the  sides  of  the  iiieisioii. 

Tlie  centre  of  the  soleiis  is  occupied  by  an  inliii-niuscuhir 
se})tum  parallel  to  the  deep  fascia,  and  sometimes  so  stout 
as  to  be  mistaken  for  it.  Close  attention  is  re({uired  for  the 
avoidance  of  this  error. 

In  the  Lower  Third  and  Belmid  th'  Ankle. — The  artery 
lies  midway  between  the  tendo  Achillis  and  the  inner  edge 
of  the  tibia  or  the  malleolus,  and  is  covered  l)y  the  super- 
ficial and  deep  fasciix),  the  hitter  of  wliicli  forms  the  annulai- 
ligament  at  the  ankle. 

Operation. — Midway  between  the  tendo  Achillis  and  in- 
ner edge  of  the  tibia,  or  a  finger's  breadth  beliind  the  latter, 
make  an  incision  three  inches  long  parallel  to  the  tibia,  if 
the  ligature  is  to  be  placed  above  the  ankle,  or  a  curved 
line  parallel  to  the  posterior  border  of  the  malleolus,  if  it  is 
to  be  placed  behind  the  ankle.  Seek  the  bundle  of  vessels, 
tear  through  the  deep  fascia  covering  them,  taking  great 
care  not  to  open  the  tendinous  sheaths  which  lie  in  front, 
and  pass  the  needle  from  without  inward. 


8^ 


PART   III. 
AMPUTATIONS. 


Amputations  may  be  in  continuity  (through  the  bone), 
or  in  contiguity  (through  a  joint);  to  the  hitter  the  tenn 
disarticulation  is  usually  applied.  The  methods  of  opera- 
tion are  classified  as  circular^  oval,  and  flap,  and  the  choice 
of  a  method  is  detennined  by  the  disposition  of  the  soft  parts 
about  the  bone,  the  facility  with  -which  the  joint  can  be 
opened  in  a  disarticulation,  the  form  of  the  resulting  stump, 
and  the  position  of  the  cicatrix.  The  comparative  merits  of 
these  methods  and  their  various  modifications  will  be  dis- 
cussed in  connection  with  the  different  operations.  They 
may  be  essentially  modified  by  accidental  circumstances,  and 
by  the  necessity  which  sometimes  arises,  as  in  cases  of  in- 
jui-y,  of  fashioning  the  flap  from  such  tissues  as  are  available. 


CIRCULAR  METHOD. 

1st  Time. — The  cutaneous  incision  should  be  made  at  a 
distance  beloAV  the  point  where  the  bone  is  to  be  divided 
equal  to  two-thirds  of  the  diameter  of  the  limb  at  that  point. 
While  an  assistant  draws  the  skin  firmly  and  evenly  to- 
ward the  root  of  the  limb,  the  operator  passes  his  hand 
below  and  beyond  it,  and  places  the  heel  of  the  knife  upon 
its  upper  surface,  its  point  directed  toward  his  own  shoulder. 
He  then  sweeps  the  knife  entirely  around  the  limb,  divid- 
ing the  skin  and  subcutaneous  cellular  tissue,  down  to  the 
enveloping  fascia,  and  terminating  the  incision  at  the  point 
where  it  began. 

2d  Time. — a.  The  skin  and  cellular  tissue  are  retracted 
and  the  muscles  divided  in  succession,  the  deeper  ones  at 


CIRCULAR    METHOD.  91 

hi«ihor  levels,  so  that  tlu'  surface  ot"  seitiim  foiiiis  ii  cone, 
the  apex  ot"  whielt  is  directed  upward.  The  luuscles  whose 
origins  are  most  distant  must  be  cut  long  to  aUow  tor  their 
greater  retraction. 

b.  [Alinson's  imthod.) — The  point  of  the  knife  is  passed 
obliquely  down  from  the  edge  of  the  skin  to  the  bone  at  the 
point  where  it  is  to  be  divided,  and  Ciirried  around  the  limb, 
always  at  the  same  angK'  witli  the  bone,  so  as  to  form  the 
muscular  cone  by  a  single  incision. 

e.  [Cutaneous  slct've.) — The  skin  and  cellular  tissue  are 
separated  cleanly  fi*om  the  deep  fascia  and  turned  back 
over  the  limb,  the  i*aw  surface  outward.  The  sleeve  thus 
formed  is  lengthened  by  drawing  it  up  and  dividing  its  at- 
tachments to  the  fascia,  care  being  taken  to  include  all  the 
subcutaneous  cellular  tissue  in  it,  until  the  dissection  has 
nearly  reacheil  the  heio^ht  at  which  the  bone  is  to  be  divided. 
The  fascia  and  muscles  are  then  cut  through  to  the  bone 
transversely  with  a  single  sweep  of  the  knife,  held  as  for 
making  the  cutaneous  incision. 

3d  Time. — Division  of  the  bone. — The  soft  parts  being 
drawn  up  and  protected  by  a  piece  of  leather  or  a  cotton 
band  four  inches  wide  and  two  feet  long,  split  for  half  its 
length  so  as  to  pass  on  each  side  of  the  bone  (called  the 
retrartor).  and  the  periosteum  having  been  divided  circularly 
with  the  knife  along  or  a  little  below  the  line  to  be  traversal 
by  the  saw,  the  operator  places  the  heel  of  the  saw  upon  the 
bone,  steadies  its  edge  with  the  thumb-nail  of  his  left  hand, 
and  draws  it  slowly  toward  himself,  cutting  a  deep  groove  in 
the  bone ;  he  then  completes  the  division  with  a  few  rapid 
strokes  of  the  instrument,  while  the  limb  is  firmly  held  by 
two  assistants,  so  as  to  prevent  binding  of  the  saw  or  splin- 
tering of  the  bone.  The  periosteum  may  first  be  dissected 
up  for  half  an  inch,  so  as  to  form  a  sort  of  curtain  to  over- 
hang the  end  of  the  bone. 

If  there  are  two  bones  the  retractor  shouM  be  split  into 
three  instead  of  two  parts,  and  the  central  one  passeil  be- 
tween the  bones.  The  saw  should  be  first  applied  to  the 
larger  bone  and,  after  cutting  a  deep  groove  in  it.  should  be 


92  AMPUTATIONS. 

inclined  backward  or  forward,  so  as  entirely  to  divide  the 
second  before  completing  the  division  of  the  first. 


OVAL  METHOD. 

A  scalpel  is  used  instead  of  the  amputating  knife;    the 

incision  is  commenced  at  the  level  at  which  the  bone  is  to 

be  divided,  is  carried  downward  on  one  side,  across  the  back 

of  the  limb,  and  upward  on  the  opposite  side  to  the  point  at 

which  it  beojan.     The  details  will  be  oriven  in  connection 

.         .  .  . 

with  certain  disarticulations  to  which  this  method  is  especially 

applicable. 

FLAP  METHOD. 

The  flaps  may  be  single  or  double,  antero-posterior,  bila- 
teral, long  rectangular  (Teale),  or  skin  flaps  with  circular 
division  of  the  muscles  (modified  flap  operation).  They  may 
be  made  by  transfixion  or  from  without  inward.'  In  making 
a  flap  by  transfixion  it  is  well  first  to  mark  its  outline  by  an 
incision  through  the  skin  and  cellular  tissue  with  a  scalpel, 
as  otherwise  there  is  danger  of  making  its  point  too  narrow 
or  its  edges  jagged.  The  point  of  the  amputating  knife  is 
then  entered  at  the  nearest  angle  of  the  incision  and  passed 
through  to  the  other,  hugging  the  bone  on  its  way,  and  the 
cut  made  steadily  downward  and  outward,  with  sawing 
movements  of  the  knife.  It  is  then  reentered  and  brought 
out  at  the  same  points,  but  passing  on  the  opposite  side  of 
the  bone,  and  the  second  flap  cut  in  the  same  manner  as  the 
first.  The  fibres  on  each  side  of  the  bone  which  have  es- 
caped are  then  divided,  the  retractor  applied,  and  the  bone 
sawed  through  as  above. 

In  cutting  a  flap  from  without  inward  the  scalpel  must 
be  entered  at  one  of  the  angles  of  the  base  of  the  proposed 
flap,  carried  along  a  curved  line  down  to  the  apex  of  the 
flap,  and  thence  up  to  the  other  angle  of  the  base.  The 
presence  of  a  tumor,  or  injury  to,  or  disease  of,  the  soft 
parts  may  render  it  necessary  to  modify  the  shape  of  the  flap 
or  vary  the  obliquity  of  the  incision,  so  as  not  to  include  any 
unfit  tissue  in  the  former. 


FLAP    METHOD.  93 

^f/nh'tird  Flip. — In  tlu'  ino(lifit'<l  flap  o|K'rati<»n  tlir  flaps 
iiicliuK'  only  tlic  .skin  an<l  sulicutancous  cellular  tissue  dis- 
secteil  off  from  the  deep  fascia  ;  the  muscles  are  divided 
transvei'sely  by  a  sweep  of  the  knife  at  the  base  of  the  flap, 
the  retractor  applied,  and  the  bone  cleaned  and  divided  a 
little  higher  u}). 

Teales  JLthod. — In  the  method  to  wliich  Mr.  Teales 
name  has  been  given  a  rery  long  rectangular  anterior  flap, 
comprising  half  the  circumference  of  the  limb  and  all  the 
tissues  down  to  the  bone,  is  made  and  doubled  back  upon 
itself,  thus  furnishing  a  thick  pad  for  the  bone  and  a  poste- 
rior cicatrix.  The  method  of  operating  is  a.s  follows  :  (Fig. 
67,  B)  A  rectangular  anterior  flap  (posterior  in  the  fore- 
arm), e<[ual  in  length  and  breadth  to  half  tlie  circumference 
of  the  limb  at  the  base  of  the  flap,  is  marked  out  by  one 
transverse  and  two  parallel  longitudinal  incisions,  the  latter 
involving  only  the  skin,  the  former  being  carried  down  to 
the  bone.  The  longitudinal  incisions  should  be  so  placed 
that  the  principal  vessels  and  nerves  will  not  be  included  in 
this  flap,  but  in  the  posterior  one,  which  is  also  bounded  by 
a  transverse  incision  carried  down  to  the  bone,  and  is  only 
one-fourth  as  long  as  the  anterior  one.  The  two  flaps  are 
now  in  turn  dissected  up  close  to  the  bone,  and  the  saw  ap- 
plied at  their  base.  After  the  vessels  have  been  secured 
the  long  flap  is  doubled  back  upon.itself  and  its  square  end 
fastened  to  that  of  the  other  with  sutures  ;  two  or  three 
points  of  suture  are  also  required  to  keep  the  sides  of  the 
short  flap  and  of  the  reversed  portion  of  the  long  flap  in 
contact  with  the  rest  of  the  latter. 

It  is  found  that  by  retraction  of  the  short  posterior  flap 
the  cicatrix  is  drawn  up  behind  and  out  of  the  way  of  the 
bone,  and  that  a  soft  mass  without  anv  large  vessels  or 
nerves  is  the  result  of  the  partial  atrophy-  of  the  long  flap, 
and  foims  an  excellent,  non-sensitive  stump.  The  principal 
objection  to  this  method,  and  one  which  greatly  restricts  its 
applicability,  is  the  great  length  of  the  anterior  flap,  which 
can  be  obtained  in  many  ciises  only  by  dividing  the  bone 
much  higher  up  than  would  otherwise  be  necessary. 


94  AMPUTATIONS. 

Lorifi  Anterior  Flap. — An  anterior  flap,  its  length  some- 
what greater  than  the  antero-posterior  diameter  of  the  linih 
at  its  base,  is  cut  by  transfixion,  or  from  Avithout  inward ; 
the  posterior  muscles  and  segment  of  skin  are  cut  straight 
across  a  little  below  the  point  of  division  of  the  bone,  and 
the  anterior  flap  brought  down  to  cover  their  cut  surfoce. 
This  method  furnishes  a  good  covering  for  the  bone,  free 
drainage  for  the  secretions  of  the  wound,  and  a  well-placed 
cicatrix. 

In  every  amputation  it  is  well  to  dissect  out  the  main 
nerve  trunks,  and  cut  them  off  high  up  between  the  muscles, 
so  that  their  ends  may  not  become  embedded  in  the  cicatrix 
or  involved  in  the  suppuration. 

The  choice  of  one  or  another  method  will  often  be  deter- 
mined by  the  anatomical  and  pathological  circumstances  of 
the  case.  When  any  one  may  be  used,  the  preference  is 
usually  given  now  to  the  modified  and  to  the  long  anterior 
flap  operations. 


AMPUTATION  OF  THE  FINGERS. 

Phalanges. — When  the  injury  or  disease  is  limited  to 
one  or  two  fingers,  and  it  is  of  such  a  nature  that  the  member 
Avill  be  useless,  if  preserved,  the  afi'ected  phalanx  or  finger 
should  be  removed  without  hesitation ;  but  usually  it  is  de- 
sirable to  save  as  much  as  possible  of  the  parts,  and  there- 
fore whenever  a  choice  can  be  made  amputation  in  continuity 
is  to  be  preferred  to  disarticulation  higher  up.  The  inci- 
sions should  be  so  arranged  that  the  cicatrix  will  not  lie  upon 
the  palmar  surface,  and  for  this,  as  well  as  for  anatomical 
reasons,  the  principal  flap  should  be  taken  from  the  flexor 
aspect.  'Ho  special  directions  are  required  for  amputation 
or  disarticulation  0/  the  middle  and  distal  phalanges.  For 
amputation  through  the  shaft  the  incision  may  be  circular 
with  a  lono-itudinal  addition  one- third  of  an  inch  lonor  on 
each  side,  or  the  single  anterior  flap  ])y  transfixion  may  be 
used.  In  disarticulation  it  is  best  to  enter  the  joint  from 
the  dorsal  side  with  a  narrow-bladed  knife,  and  cut  the  ante- 
rior flap  by  carrying  the  knife  through  the  joint  and  then 
forward,  huojo-ino;  the  bone. 


AMPUTATION    OF    THE    FINGERS.  95 

It  must  be  renieinbered  tliat  tlie  folds  on  tlie  palmar  sur- 
fiico  of  :i  finder  do  not  ('orresjjoiid  exactly  to  the  joints;  the 
first  hein^  half  an  inch  beyond,  the  middle  one  a  line  above, 
and  the  distal  one  a  (juarter  of  an  inch  above  the  articular 
surfaces,  and  also  that  the  prominence  of  a  knuckle  when 
the  finger  is  flexed  is  formed  entirely  by  the  head  of  the 
proximal  and  not  by  the  base  of  the  distal  phalanx.  When 
the  tissues  have  not  become  thickened  and  infiltrated,  the 
articular  depressions  can  also  be  felt  uj>on  the  sides. 

Amputation  through  the  3Ietacarpo-phalan(jeal  Articula- 
tion.— The  articular  depression  can  be  found  very  easily  by 
passino;  the  thuml)  and  forefinger  along  the  sides  of  the 
finger,  especially  if  the  latter  be  at  the  same  time  draAvn 
forcibly  away  from  its  metacarpal  bone. 

The  incision  should  be  commenced  over  the  dorsum  of 
the  metacarpal  bone  a  quarter  of  an  inch  above  the  articu- 
lation, carried  through  the  interdigital  web,  and  then  back 
on  the  palmar  face  to  a  point  a  quarter  of  an  inch  above  the 
flexor  fold  (Fig.  54,  (7);  a  similar  incision,  beginning  and 
ending  at  the  same  points,  is  made  on  the  other  side  of  the 
finger,  the  flaps  dissected  back,  the  lateral  ligaments  divided 
while  the  finger  is  drawn  first  to  one  side  and  then  to  the 
other  so  as  to  facilitate  access  to  them  and  at  the  same 
time  make  them  tense,  and  then  the  tendons  and  the  re- 
mainder of  the  capsule  divided  as  flie  finger  is  withdrawn. 

Or  an  incision  may  be  made  only  on  the  side  correspond- 
ing to  the  right  hand  of  the  operator,  the  flap  dissected 
back  to  the  joint,  the  lateral  ligament  divided,  the  knife 
carried  transversely  through  the  joint,  dividing  the  tendons 
and  the  other  lateral  ligament,  and  the  other  flap  cut  from 
w^ithin  outward,  care  being  taken  to  make  it  sufiiciently 
broad. 

The  head  of  the  metacarpal  bone  should  be  removed  only 
in  cases  where  it  is  more  desirable  to  diminish  the  deformity 
than  to  preserve  the  strength  of  the  hand. 

An  artery  on  each  side  will  have  to  be  secured,  and  the 
wound  closed  with  sutures. 

The  incisions  may  be  advantageously  modified  for  the 
index  and  little  fingers  by  making  a  full  lateral  flap  on  the 
free  side  and  carrying  the  incision  transversely  across  the 


96 


AMPUTATIONS, 


palmar  surface  to  the  angle  of  the  web,  and  thence  obliquely 
back  to  the  knuckle  (Fig.  54,  E). 


AMPUTATION  OF  THE  METACARPAL  I30NES. 


As  the  articulations  of  the  1st  and  5th  metacarpal  bones 
with  the  carpus  do  not  comnninicate  with  the  other  and 
larger  synovial  sacs,  these  bones  may  be  entirely  removed 
without  much  danger  of  setting  up  inflammation  within  tlie 


Fig.  54. 


A.  Disarticulation  of  phalanx,  anterior  flap  B.  Amputation  in  continuity,  circular. 
C.  Metacarpo-phalangeal  disarticulation,  h.  Amputation  of  a  metacarpal  bone  in  con- 
tinuity. E.  Disjirticulation  of  little  finger,  F.  Disarticulation  of  5th  metatarsal.  G. 
Amputation  of  wrist,  circular.     H.  Amputation  of  wrist.     (Dubrueil.) 

wrist-joint,  l)ut  in  the  case  of  the  otlier  three  amputation  in 
continuity  is  preferable  to  disarticulation.  The  relations  of 
the  synovial  sheaths  of  the  flexor  tendons  are  also  of  im- 
portance   in    the    operation.     There   is    no  communication 


AMPUTATION    AT    THE    WRIST.  97 

between  the  main  slieatli  in  tlic  palm  of  the  hand  and  the 
sheaths  of  tlie  -d,  'Jd,  and  4tli  fiiit^ors,  and  consequently,  if 
the  tendons  are  divided  as  low  down  as  the  metacaijMt-pha- 
langeal  articulation,  inflammation  of  the  main  sheath  with 
all  its  disastrous  consequences  will  pi-obably  he  av(^ide<l. 

The  incisions  are  the  same  as  for  amputation  through  the 
metacarpo-phalangeal  articulation,  with  a  prolongation  up- 
ward as  far  as  may  be  necessary  over  the  back  of  the  bone 
(Fig.  54,  D).  After  its  posterior  and  lateral  surfaces  have 
been  bared,  the  bone  is  cut  through  with  pliers  at  the  point 
determined  on,  and  the  distal  fragment  is  raised  from  its 
bed,  and,  beginning  at  the  upper  end,  its  under  surface 
carefully  separated  from  the  soft  parts. 

In  disarticulation  of  the  fifth  metacarpal,  the  incision 
should  be  made  along  the  inner  border  of  the  hand,  and 
carried  down  to  the  bone  between  the  skin  and  the  abductor 
minimi  dicriti  rather  than  through  the  fibres  of  the  latter 
(Fig.  54,  F).  This  gives  easier  access  to  the  palmar  liga- 
ments uniting  the  bone  to  the  carpus.  The  lower  end  of 
the  incision  should  form  a  loop  with  its  centre  in  the  inter- 
digital  web,  and  its  point  on  the  line  of  the  knuckle. 


AMPUTATION  AT  THE  WRIST. 

{Radio-carpal  Disarticulation.) 

Circular  Method  (Fig.  54,  G-). — While  an  assistant  re- 
tracts the  skin  upon  the  forearm,  the  operator  sweeps  his 
knife  transversely  around  the  wrist,  half  an  inch  below  the 
point  of  the  styloid  process  of  the  radius.  The  skin  and  as 
much  cellular  tissue  as  possible  are  divided  and  dissected 
back  as  far  as  the  joint,  which  is  then  opened  by  entering 
the  point  of  the  knife  just  below  the  styloid  process  of  the 
radius,  and  the  disarticulation  completed  while  the  hand  is 
drawn  firmly  away  from  the  arm. 

Antero-jyostcrior  Flaps. — The  absence  of  muscular  fibres 
at  the  wrist  deju-ives  this  method  of  most  of  the  advantages 
which  it  oifers  at  other  points,  and  the  projection  on  the  pal- 
mar surfiice  of  the  trapezium  and  pisiform  bones  renders  its 

9 


98  AMPUTATIONS. 

execution  difficult,  and  makes  it  practically  identical  with 
the  circular  method  supplemented  by  lateral  incisions.  It 
should  be  reserved  for  cases  in  which  the  skin  is  so  infil- 
trated that  it  cannot  be  readily  dissected  back. 

An  incision  curved  downward  is  carried  across  the  back 
of  the  wrist  from  one  styloid  process  to  the  other,  the  flap 
dissected  up,  the  hand  flexed  forcibly,  the  extensor  tendons 
divided,  the  joint  opened  beneath  them,  and  the  palmar  flap, 
which  should  extend  as  flir  down  as  the  base  of  the  meta- 
carpal bones,  cut  from  within  outward. 

Or  the  palmar  flap  may  be  made  from  without  inward,  or 
by  transfixion,  before  the  joint  has  been  opened. 

External  Lateral  Flap.  DubrueiP  (Fig.  54,^). — The 
hand  is  pronated,  and  the  operator  makes  a  curved  incision, 
which,  beginning  on  the  dorsal  aspect  a  quarter  of  an  inch 
below  the  radio-carpal  articular  line,  at  the  junction  of  the 
outer  and  middle  thirds,  passes  downward,  crosses  the  outer 
side  of  the  first  metacarpal  bone  at  its  centre,  and  returns  to 
a  point  on  the  palmar  surface  opposite  that  at  which  it  began. 
Its  two  ends  are  then  joined  by  a  transverse  incision  passing 
around  the  inner  side  below  the  end  of  the  ulna.  The  ex- 
ternal flap  is  dissected  up,  the  joint  opened  at  the  radial 
side,  and  the  disarticulation  completed. 


AMPUTATIOX  OF  THE  FOREARM. 

The  forearm  may  1»e  divided,  with  reference  to  surgical 
considerations,  into  upper,  middle,  and  lower  thirds.  Its 
shape  is  cylindrical  near  the  elbow,  and  gradually  flattens 
and  narrows  toward  the  wrist.  The  lower  half  of  the  radius 
and  the  whole  length  of  the  ulna  are  subcutaneous.  The 
coverings  of  the  lower  third  are  composed  almost  exclusively 
of  skin  and  tendons,  while  thick  muscular  masses  cover  the 
upper  two  thirds,  especially  on  the  anterior  aspect.  The 
absence  of  suitable  coverinors  in  the  lower  third,  and  the 
presence  there  of  so  many  synovial  sheaths,  the  inflamma- 
tion of  which  may  give  rise  to  dangerous  complications,  have 

^  Medeeine  Oiieratoire,  p.  171. 


AMPUTATION  OF  THE  FOREARM.       99 

leil  some  sunreon.s  (Baron  Larrey,  Sudillot)  to  advise 
strongly  against  amputating  at  this  part.  On  the  other 
hand,  it  is  important  for  the  subse^juent  usefulness  of  the 
limb  that  the  movements  of  pronation  and  supination  should 
be  preserve<l,  and  this  can  only  be  done  by  dividing  the 
bones  below  the  insertion  of  the  pronator  radii  teres,  which 
is  just  above  the  middle  of  the  radius:  if  the  division  has 
to  be  made  above  this  point  the  rule  is  to  save  as  much  as 
possible,  especially  the  insertion  of  the  biceps. 

For  the  reasons  stated,  the  only  method  applicable  to  the 
lower  third  is  the  circular  one,  and  if  the  conicity  of  the 
limb  or  the  infiltration  of  the  parts  should  otherwise  render 
it  impossible  to  carry  the  dissection  of  the  cutaneous  sleeve 
to  a  suflficient  height,  the  circular  incision  must  be  supple- 
mented by  a  short  longitudinal  one  in  front.  The  division 
of  the  tendons  should  be  on  the  same  level  with  that  of  the 
bone,  and  is  best  accomplished  by  passing  the  knife  under 
them,  and  cutting  directly  outward. 

In  the  upper  tAvo-thirds  the  difficulty  of  dissecting  a 
cutaneous  sleeve  is  likely  to  be  still  greater,  and  has  led  to 
general  rejection  of  the  circular  method.  On  the  other 
hand,  lateral  flaps  are  impossible,  and  the  bones  have  a 
tendency  to  project  at  the  angles  if  antero-posterior  flaps 
are  made.  Many  methods  have  been  proposed  to  obviate 
this  difficulty,  in  all  of  which  the  essential  point  is  the  same, 
namely,  to  divide  the  bones  at  least  half  an  inch  above  the 
angles  of  the  incision  through  the  skin.  Sedillot  made 
short  thin  musculo-cutaneous  flaps,  and  divided  the  deep 
muscles  obliquely  according  to  Alanson's  method  (p.  91); 
Richet  makes  short  flaps,  including  all  the  soft  parts,  dis- 
sects them  up  circularly  from  the  bones  for  about  three- 
quarters  of  an  inch,  and  divides  the  latter  at  the  height  thus 
reached.  Tillaux  recommends  short  skin  flaps  to  be  dis- 
sected up  for  three-quarters  of  an  inch  above  their  base, 
and  then  short  muscular  flaps  to  be  made  parallel  to  the 
former  bv  transfixion  at  the  higher  level.  When  there  is 
sufficient  available  material  on  the  back  of  the  arm  for  a 
long  flap,  Teale's  method  gives  good  results. 

High  up  in  the  upper  third,  where  the  position  of  the 
bones  is  more  central,  and  thick  muscular  masses  lie  upon 
the  sides,  the  short  flaps  should  be  lateral. 


100  AMPUTATIONS, 


AMI'UTATION  AT  THE  ELBUW-JOINT. 

The  guides  to  the  articulation  are  the  epitrochlea  on  the 
inner,  the  epicondyle  and  the  head  of  the  radius  on  the 
outer  side.  The  smooth  rounded  prominence  formed  by  the 
hitter  can  be  readily  felt  about  half  an  inch  below  the  epi- 
condyle ;  and  the  interarticular  line  starting  from  it  passes 
at  first  transversely  and  then  downward  and  inward  to- 
ward  a  point  an  inch  below  the  epitrochlea,  and  forms  an 
angle,  opening  inward,  with  the  transverse  diameter  of  the 
lower  end  of  the  humerus.  It  is  therefore  unnecessary  to 
expose  the  epicondyle  and  epitrochlea  in  disarticulating ; 
and  these  relative  positions  should  be  constantly  kept  in 
mind  during  the  operation.  The  skin  is  freely  movable  in 
front,  but  is  adherent  to  the  ulna  behind. 

The  methods  in  common  use  are  the  anterior  flap,  lateral 
flap,  and  circular. 

Anterior  Flap. — The  joint  may  be  opened  (r/)  from  be- 
hind, or  {h)  from  in  front. 

a.  From  behind.  (Sedillot.) — The  forearm  is  flexed, 
and  an  incision,  slightly  convex  downward  and  interesting 
only  the  posterior  third  of  the  circumference,  is  made  one 
and  a  half  inches  below  the  tuberosities  of  the  humerus. 
The  skin  is  dissected  up  to  the  tip  of  the  olecranon,  the 
tendon  of  the  triceps  divided,  the  point  of  the  knife  passed 
into  the  joint  and  carried  first  to  one  side  and  then  to  the  other, 
cutting  the  posterior  and  lateral  ligaments.  A  longitudinal 
incision  two  and  a  half  inches  long  is  then  carried  down- 
ward from  the  outer  end  of  the  first,  the  forearm,  still  flexed, 
is  pressed  backward  and  inward,  and  the  disarticulation 
readily  completed  by  passing  the  knife  through  the  joint, 
and  cutting  down  and  out  on  the  anterior  aspect  while  the 
skin  is  forcibly  retracted. 

h.  From  in  front.  (Fig.  55,  A.) — The  flap  may  be 
made  by  transfixion,  or  from  without  inward ;  in  either  case 
it  should  be  at  least  three  inches  long,  and  its  base  should 
be  parallel  to  and  three-quarters  of  an   inch  below  a  line 


AMPUTATION    AT    THE    ELBOW-JOINT 


101 


Fiu.  55. 


drawn  throu^li  tlie  opicondyle  and  the  cpitiorldca.      Some 
surgeons  pretbr  to  make  the  line  of  the  base  oblicpie  down- 
ward and  outward,  because  the  muscles  on  the  outer  side 
have  their  origins  at  higher  points 
on   the  humerus,  and  retract  more 
than  those  on  the  inner  side.     The 
posterior  incision  should  be  slightly 
convex  downward,  and  should  begin 
and  end  at  the  same  points  as  the 
anterior  one. 

The  head  of  the  radius  is  then 
sought  for,  and  the  joint  opened  by 
entering  the  knife  between  it  and 
the  humerus  and  completely  dividing 
the  external  lateral  ligament.  The 
capsule  is  divided  in  front  by  pass- 
ing the  point  of  the  knife  along  the 
edge  of  the  ulna  over  the  coronoid 
process  to  the  internal  lateral  liga- 
ment, which  should  be  cut  as  high 
as  possible.  The  olecranon  is  dis- 
engaged from  the  humerus  by  draw- 
ing it  down  forcibh^  the  attachment 
of  the  triceps  divided,  the  knife 
passed  behind  the  bone,  and  the  re- 
maining tissues  divided  from  within 

X  1  Amputation  at  the  elbow-joiut. 

A.  Anterior  flap.      B.  External 
flap.     C.  Circular  method. 

Lateral  flap.  (Fig.  55,  B.) — An 
external  flap  four  or  five  inches  long  is  made  by  transfixion 
from  a  point  in  the  median  line  in  front,  a  finger's  breadth 
below  the  bend  of  the  elbow^  or  from  without  inward  by  an 
incision  beginning  at  the  same  point  and  ending  half  an  inch 
higher  on  the  posterior  fiice  of  the  ulna.  A  second  incision 
is  made  transversely  across  the  inner  side  of  the  arm  about 
an  inch  below  the  upper  end  of  the  first.  The  radio-humeral 
joint  is  opened,  and  the  disarticulation  completed  as  before. 

Instead  of  a  single  external  flap,  two  lateral  flaps  may  be 

made,  but  the  external  should  be  half  an  inch  longer  than 

the  internal  one. 

9* 


102  AMPUTATIONS. 

Circular.  (Fig.  bb,  C.) — An  incision,  transverse  or  a 
little  lower  on  the  outer  than  on  the  inner  side,  is  made 
about  the  limb  three  and  a  half  inches  below  the  epi- 
trochlea,  and  carried  doAvn  to  the  enveloping  fascia;  the 
cutaneous  sleeve  is  dissected  up  for  about  an  inch,  and  the 
muscles  divided  transversely  at  its  base.  They  are  then 
retracted  forcibly  by  an  assistant  so  as  to  form  a  cone  with 
its  apex  directed  downward,  and  the  deep  muscles  of  the 
anterior  aspect  are  again  divided  transversely  on  a  level 
with  the  radio-humeral  articulation,  the  external  lateral 
ligament  being  included  in  the  incision  and  the  joint  there- 
by opened.  The  disarticulation  is  completed  as  before 
described. 

AMPUTATION  OF  THE  ARM. 

This  may  be  performed  at  any  point  below  the  attach- 
ments of  the  muscles  of  the  axilla.  Disarticulation  at  the 
shoulder  is  preferable  to  amputation  in  continuity  above 
these  attachments.  As  the  bone  is  centrally  placed  and 
well  covered  on  all  sides,  any  one  of  the  usual  methods  of 
amputation  may  be  employed.  As  a  general  rule  the  biceps 
should  be  divided  at  a  lower  level  than  the  other  muscles 
because  it  is  not  adherent  to  the  humerus,  and  therefore 
retracts  more  than  the  others.  The  circular  incision  should 
be  half  an  inch  lower  on  the  inner  than  on  the  outer  side. 
In  muscular  subjects  flaps  should  be  cut  rather  thin,  and, 
when  possible,  it  is  better  that  the  main  artery  should  be  in 
the  posterior  flap. 

AMPUTATION  AT  THE  SHOULDER-JOINT. 

General  Considerations. — The  exposed  position  and  great 
accessibility  of  the  head  of  the  humerus  have  led  to  the 
suggestion  of  many  02:)erative  metliods,  most  of  which  can 
be  performed  with  much  ease  and  regularity  upon  the  cada- 
ver, and  yield  good  results  in  actual  practice,  amputation 
at  the  shoulder-joint  being,  jjerhaps,  the  most  successful  of 
the  major  operations.  But  as  the  operation  is  usually  ren- 
dered necessary  by  malignant  disease  or  compound  fracture 
of  the  humerus,  or   by   aneurism    of  the    axillary  artery, 


AMPUTATION  AT  THE  SHOULDER- JOINT.   103 

under  circiiinstanccs  Avliirli  iiiuko  it  very  dilficult,  il'  not  im- 
possible, to  follow  reguliir  nietliods,  it  is  more  important  to 
j)e  familiar  with  the  anatomy  of  the  parts  and  tlie  general 
principles  i^overniiii^  all  the  methods  than  with  the  details 
of  the  different  ones. 

The  size  of  the  axillary  artery  and  the  difficulty  of  effi- 
ciently compressing  the  subclavian  make  the  management  of 
the  artery  an  element  of  prime  importance  in  this  operation. 
The  joint  should  be  ap}»roached  from  the  outer  side,  and 
the  artery  divided  from  within  outward  after  disarticulation, 
an  assistant  passing  Iris  thumb  into  the  wound  above  the 
knife  and  compressing  the  vessel  before  it  has  been  cut.  Or 
the  artery  may  be  exposed  during  the  operation  and  tied 
before  it  is  cut.  ' 

Pressure  upon  the  subclavian  may  be  made  by  the  tliund) 
of  an  assistant  standing  behind  the  patient,  or  by  the  well- 
padded  handle  of  a  door  key  or  tourniquet,  or  a  rubber  tube 
or  cord  tightly  encircling  the  axilla,  scapula,  and  clavicle. 

The  subsequent  retraction  of  the  pectoralis  magnus  and 
latissimus  dorsi  leads  to  gaping  of  the  wound  and  the  for- 
mation of  a  broad,  unsightly,  triangular  cicatrix.  This  must 
be  met  by  retaining  all  the  skin  for  the  first  two  or  three 
inches  in  the  flaps,  not  allowing  the  incisions  to  diverge  from 
one  another  until  the  end  of  the  flap  is  nearly  reached. 
This  precaution  also  insures  ample  covering  for  the  project- 
ing acromion.  The  outer  flap  should  comprise  the  entire 
thickness  of  the  deltoid  so  that  the  gap  left  by  the  head  of 
the  humerus  may  be  properly  filled,  and  it  should  be  dis- 
sected up  close  to  the  bone  so  as  to  avoid  injury  to  the  trunk 
of  the  posterior  circumflex  artery. 

Instead  of  attempting  to  separate  the  capsule  at  its  attach- 
ment to  the  upper  edge  of  the  glenoid  cavity  by  passing  the 
point  of  the  knife  under  the  acromion,  it  is  better  to  divide 
it  near  its  centre  by  drawing  the  edge  of  the  knife  across 
the  upper  surface  of  the  head  of  the  humerus ;  and  in  all 
incisions  beginning  between  the  acromion  and  coracoid  pro- 
cess the  point  of  the  knife  should  be  passed  directly  down 
to  the  humerus  so  as  to  divide  the  strong  fibrous  arch  con- 
necting the  two  processes. 

Oval  Method  (Baron  Larrey).  (Fig.  56,  ^.)— A  longi- 
tudinal incision  involving  all  the  tissues  down  to  the  bone  is 


104 


AMPUTATIONS. 


made  on  the  outer  aspect  of  the  shoulder  from  the  edge  of 
the  acromion  to  a  point  one  inch  below  the  neck  of  the 
humerus,  and  an  oval  one  interesting  the  skin  only  is  then 
carried  from  its  lower  end  around  the  arm,  crossing  its  inner 
side  about  an  inch  below  the  border  of  the  axilla.  The 
flaps  thus  marked  out  are  dissected  up,  the  anterior  one 
carefully,  until  the  tendon  of  the  pectoralis  magnus  is  ex- 
posed, and  divided  close  to  its  insertion,  the  posterior  one 
more  boldly,  but  close  to  the  bone,  so  as  to  avoid  injury  to 
the  trunk  of  the  circumflex  artery.  The  capsule  is  freely 
divided  across  the  head  of  the  humerus,  the  arm  rotated 


Fig.  56. 


Disarticulation  at  the  sliouldor.     A.  Oval  method.     B.  Method  by  double  flaps. 

inward  and  then  outward  so  as  to  facilitate  the  division  of 
the  tendons  of  the  articular  muscles,  which  is  best  accom- 
plished by  cutting  directly  upon  the  tuberosities,  the  hume- 
rus thus  liberated  is  thrown  outward  by  adducting  the  elbow, 
the  knife  is  passed  behind  it  and  carried  down  and  out 
through  the  cutaneous  incision  on  the  inner  side,  while  an 
assistant  compresses  the  artery  in  the  wound. 

The  resulting  wound  is  comparatively  small,  allows  free 
drainage  at  its  lower  angle,  is  likely  to  unite  by  first  inten- 
tion in  its  upper  half,  and  usually  leaves  a  linear  cicatrix. 

After  cutting  through  the  tendon  of  the  pectoralis  mag- 


AMPUTATION    AT    THE    SHOU  LDER- JOINT.      105 

nils,  VcriuMiil  isolates  the  biceps  and  coraco-brac-liialis  with 
his  fin<^ers,  divides  them,  seeks  for  tlie  artery,  and  ties  it 
rather  high  up  before  continuing  the  operation. 

It  is  sometimes  not  easy  to  reacli  and  divide  tlie  ])road 
tendon  of  the  subscapuhiris ;  and  when  the  humerus  is 
broken  it  is,  of  course,  impossilde  to  use  it  as  a  lever  to 
force  the  head  of  the  bone  out  of  the  socket,  and  this  part 
of  the  operation  may  thereby  be  rendered  somewhat  diffi- 
cult. These  and  the  liemorrhage  from  tlie  branches  of  the 
posterior  circumflex  are  the  principal  objections  to  this 
method,  which  has,  nevertheless,  yielded  excellent  results. 

The  articulation  is  uncovered  more  freely  Ijy  any  of  the 
double  flap  methods  in  which  an  external  flap  is  fashioned 
out  of  the  deltoid  muscle.  Of  these  the  Lisfranc  metho<l 
may  be  taken  as  the  type,  premising  only  that  while  the 
opening  of  the  articulation  by  transfixion  is  very  easy  of 
execution  upon  the  cadaver,  it  is  sometimes  impossible  upon 
the  living  subject,  and  ina})plicable  to  cases  of  malignant 
disease  of  the  humerus.  Under  such  circumstances  the 
flaps  must  be  made  by  dissection  from  without  inward. 

Douhle  Flap  MrtJiod  (Lisfranc).  (Fig.  56,  J5.)— Right 
shoulder.  While  the  arm  is  abducted  the  surgeon  enters 
the  point  of  a  two-edged  amputating  knife  at  the  outer  side 
of  the  coracoid  process,  carries  it  across  the  outer  aspect  of 
the  head  of  the  humerus,  and  brinscs  it  out  a  little  below  the 
posterior  border  of  the  acromion.  He  then  raises  the  fil)res 
of  the  deltoid  with  his  left  hand,  works  the  knife  downward 
around  the  head  of  the  bone,  and  cuts  a  broad  flap  about 
five  inches  long.  In  this  manoeuvre  the  joint  should  be 
opened  at  its  upper  part,  the  tendons  of  the  supra-spinatus 
and  long  head  of  the  biceps  entirely  divided,  and  those  of 
the  subscapularis  and  infraspinatus  partly  divided.  The 
arm  is  then  adducted,  the  knife  passed  through  the  joint 
to  the  inner  side,  and  a  long  inner  flap  cut  from  within  out- 
ward. 

Left  shoulder.  The  knife  is  passed  in  the  opposite  direc- 
tion, that  is,  from  below  the  acromion  behind  to  the  coracoid 
process  in  front,  and  the  operation  completed  as  on  the  right 
side. 


106 


AMPUTATIONS. 


Fig. 


Spenecs  Method. — Prof.  Spence  has  lately  introduced 
a  method,  for  which  he  claims  the  following  advantages: 
1st.  The  better  form  of  the  stump.  2d.  The  division  of  the 
posterior  circumflex  artery  only  in  its  terminal  branches  in 
front.  3d.  The  crrcat  ease  with  which  disarticulation  can 
be  accomplished.  Another  advantage  is  that  an  operation 
for  excision  of  the  head  of  the  humerus  can  be  easily  trans- 
formed into  a  disarticulation  by  its  means,  should  that  be 
found  necessary. 

He  describes  the  operation  as  follows  (Fig.  57):^  "The 
arm  being  slightly  abducted,  and  the  humerus  rotated  out- 
wards, I  cut  down  upon  the  head  of 
the  humerus  immediately  external  to 
the  coracoid  process,  and  carry  the  in- 
cision down  through  the  clavicular  fibres 
of  the  deltoid  and  pectoralis  major  mus- 
cles, till  I  reach  the  humeral  attachment 
of  the  latter  muscle,  which  I  divide.  I 
then,  with  a  orentle  curve,  carry  mv  inci- 
sion  across  and  fairly  through  the  lower 
fibres  of  the  deltoid  toward,  but  not 
through,  the  posterior  border  of  the 
axilla.  Unless  the  textures  be  much 
torn,  I  next  mark  out  the  line  of  the 
lower  part  of  the  inner  section  by  carry- 
ing an  incision  through  the  skin  and  fat 
only,  from  the  point  where  my  straight 
incision  terminated,  across  the  inside  of 
the  arm  to  meet  the  incision  at  the  outer 
part.  If  the  fibres  of  the  deltoid  have 
been  thoroughly  divided,  the  flap,  together  with  the  posterior 
circumflex  artery,  can  be  easily  separated  by  the  point  of  the 
finger  from  the  bone  and  joint,  and  drawn  upward  and 
backward  so  as  to  expose  the  head  and  tuberosities  without 
further  use  of  the  knife.  The  tendinous  insertions  of  the 
capsular  muscles,  the  long  head  of  the  biceps,  and  the  cap- 
sule are  next  divided  by  cuttins:  directly  on  the  bone.  Dis- 
articulation  is  then  accomplished,  and  the  limb  removed  by 
dividing  tlie  remaining  soft  parts  on  the  axillary  aspect. 


Disarticulation  at  the  shoul- 
der.    Spence" s  method. 


^  Lectures  on  Surgery,  2d  ed.,  vol.  ii.  p.  G62.     Ji.din.,  1876. 


AMPUTATION    OF    THE    TOES 


107 


"  III  cases  wlii'iT  tlio  limb  is  very  muscular,  1  dissect  the 
skill  ami  I'at  trom  the  rleltoid  at  the  lower  |)art,  and  then 
divide  the  muscular  fibres  higiher  up  by  a  second  incision,  so 
as  to  avoid  redundancy  of  muscular  tissue." 

AMPUTATION  OF  THE  TOES. 


Fig    r,8. 


The  different  phalanges  of  the  toes  may  be  removed  by 
the  same  methods,  and  at  the  same  points,  as  those  of  the 
fingers,  but  experience  has  shown  that,  except  for  the  great 
toe,  it  is  better  to  disarticulate  at  the 
metatarso-phalangeal  joint,  the  pre- 
servation of  a  portion  of  a  toe  being 
a  source  of  discomfort  rather  than  an 
advantaore.  In  the  case  of  the  great 
toe  it  is  desirable  to  save  as  much  as 
possible,  and  amputation  in  continuity 
is  to  be  preferred  to  disarticulation. 
In  all  operations  upon  the  foot  the  in- 
cisions should  be  so  arranged  that  the 
cicatrices  will  not  occupy  the  plantar 
surface.  It  must  be  remembered  that 
the  web  between  the  toes  lies  far 
below  the  metatarso-phalangeal  joint. 
(Fig.  58).  ■ 

The  incision  should  be  commenced 
on   the  dorsal  surface  a   little  above 

the  joint,  carried  directly  down  the  bone  for  about  an  inch, 
and  then,  diverging  abruptly,  into  the  web,  straight  across 
in  the  digito-plantar  fold,  and  back  on  th  eother  side  to  the 
point  of  divergence  (Fig.  59,  A).  If  the  strong  flexor  ten- 
dons have  been  completely  divided  it  will  then  be  found  easy 
to  disarticulate  bv  enterintr  the  knife  at  the  side  of  the  joint. 
This  oval  incision  is  better  than  the  two  lateral  semilunar 
flaps,  because  its  cicatrix  does  not  extend  into  the  sole  of 
the  foot. 

The  distal  phalanx  of  the  great  toe  may  be  remove<l 
according  to  the  methods  described  for  the  corresponding 
part  of  the  thumb  and  fingers  (p.  94). 


Relations  of  the  web  and  me- 
tatarso-phalangeal joint. 


108 


AMPUTATIONS. 


Disarticulation  of  the  great  toe  at  the  metatarso-plialan- 
geal  joint  may  be  done  according  to  the  method  just  -de- 
scribed for  the  other  toes,  or  with  a  hirge  internal  flap.  In 
the  hitter  case  an  incision  (Fig.  60,  A)  is  begun  on  the  outer 
side  of  the  extensor  tendon  just  below  the  joint,  and  carried 


Fig.  59. 


Fig.  go. 


Amputation  of  the  gi'eat  toe . 


straight  down  to  the  head  of  the 


first  phalanx.  From  its  lower  end 
a  transverse  incision  is  carried 
around  the  inner  side  of  the  toe 
to  the  outer  edge  of  the  flexor  ten- 
don, and,  the  toe  being  then  for- 
cibly extended,  a  plantar  incision 
is  carried  from  the  end  of  the 
transverse  incision  (Fig.  60,  E)^ 
along  the  outer  side  of  the  flexor 
tendon  to  the  digito-plantar  fold, 
and  thence  transversely  around  the 
outer  side  of  the  toe  to  rejoin  the 
first  incision  near  its  centre. 

The    internal    flap  is  then    dis- 
sected   from    below    upward,    the 
extensor  tendon  divided  high  up,  the  lateral  ligaments  di- 
vided, the  knife  passed  through  the  joint,  and  the  remaining 
soft  parts  cut  from  within  outward. 

The  same  incisions  made  somewhat  lower  down  may  be 
used  for  amputation  in  continuity,  but  usually  the  shape 
and  position  of  the  flaps  will  be  determined  by  the  nature 
and  extent  of  the  injury  which  makes  the  operation  neces- 
sary. 


Amputation  of  the  toes  and  meta 
tarsal  bones 


AMPUTATION    OF    A    METATARSAL    BONE.      109 

Aniputdtion  of  two  adjoinini/  Toes. — The  dorsal  incision 
should  hc'^hi  in  the  intermetatarsal  space  just  above  the 
level  of  the  joint  (Fig.  59,  B\  extend  down  to  the  begin- 
ning of  the  web,  diverge  obliquely  to  the  adjoining  web, 
cross  the  plantar  surface  in  the  digito-plantar  fold  of  both 
toes,  and  return  through  the  other  adjoining  web  to  the 
point  of  divergence.  Each  toe  is  then  removeil  separately 
after  division  of  its  tendons  and  lateral  ligaments. 


AMPUTATION  OF  A  METATARSAL  BONE. 

Amputation  in  continuity  is  much  to  be  preferred  to  dis- 
articulation on  account  of  the  extent  of  some  of  the  syno- 
vial sacs,  the  attachments  of  certain  muscles,  and  the  im- 
portance of  some  of  the  bones  in  preserving  the  relations 
of  the  others.  The  synovial  sac  which  forms  part  of  the 
articulation  between  the  first  cuneiform  and  first  metatarsal 
bones  is  isolated  from  the  others,  but  the  attachment  of  the 
peroneus  longus  to  the  base  of  the  latter  bone  renders  its 
preservation  especially  important.  There  is  also  a  separate 
synovial  sac  for  the  articulation  between  the  cuboid  and  the 
fourth  and  fifth  metatarsals.  The  base  of  the  fifth  meta- 
tarsal is  easily  recognized  by  the  prominence  which  it  forms 
on  the  outer  side  of  the  foot :  that  of  the  first  metatarsal  is 
three-fourths  of  an  inch  anterior  to  the  other,  and  is  the  first 
prominence  encountered  by  the  finger  when  it  is  passed  from 
before  backward  along  the  inner  side  of  the  bone. 

The  incision  begins  on  the  dorsal  aspect  at,  or  a  little  be- 
low, the  point  at  which  the  bone  is  to  be  divided,  is  carried 
down  well  below  the  metatarso-phalangeal  joint  (Fig.  -39, 
(7),  diverges  into  the  web,  crosses  the  plantar  surface  in 
the  digito-plantar  fold,  and  returns  through  the  other  web 
to  the  point  of  divergence.  A  short  transverse  incision  is 
made  through  the  skin  at  its  upper  end  to  fiicilitate  division 
of  the  bone,  which  is  then  efi'ected  with  cutting  pliers  or  a 
chain  saw  after  the  soft  parts  have  been  separated  on  both 
sides.  The  toe  is  then  pressed  backward,  the  cut  end  of 
the  bone  raised,  the  knife  passed  behind  it,  and  the  opera- 
tion completed  by  cutting  from  within  outward.     The  first 

10 


110  AMPUTATIONS. 

and  fifth  metacarpal  bones  should  be  cut  obliquely  so  as  to 
diminisli  the  prominence  of  tlic  stump. 

For  disarticulation  of  the  first  or  fifth  metatarsal  hones 
the  only  modification  needed  is  to  begin  the  incision  at  a 
correspondingly  higher  point — at  or  a  little  below  the  tarso- 
metatarsal joint  (Fig.  59,  D).  After  the  flaps  have  been 
dissected  up,  the  joint  is  opened  by  dividing  the  dorsal  and 
interosseous  ligaments,  and  the  bone  raised  and  separated 
from  the  remaining  soft  ^Darts. 


DISARTICULATIOX  OF  ALL  THE  METATARSAL  BOXES.  (TARSO- 
METATARSAL DISARTICULATION  ;  LISFRANC'S  OR  HEY'S 
AMPUTATION.) 

The  position  and  general  direction  of  the  tarso-metatarsal 
articulations,  as  well  as  the  peculiarity  presented  by  the 
base  of  the  second  metatarsal  bone,  are  sufficiently  well 
shown  in  Fig.  61  to  render  a  detailed  description  unneces- 
sary. The  guides  to  the  articulation  are  the  projecting 
bases  of  the  first  and  fifth  metatarsal  bones. 

The  skin  being  retracted  by  an  assistant,  the  surgeon 
makes  with  a  scalpel  a  curved  incision  across  the  dorsum  of 
the  foot  from  the  base  of  the  fifth  to  the  base  of  the  first 
metatarsal  bone.  (For  the  left  foot  the  direction  of  this 
incision  must  be  reversed.)  The  incision  should  involve  the 
skin  only,  its  centre  should  lie  half  an  inch  or  more  below 
the  centre  of  the  line  of  the  articulations,  and  it  should  be- 
gin and  end  upon  the  sides  of  the  foot  at  their  junction  with 
the  sole.     (Fig.  61.). 

A  plantar  flap  should  then  be  marked  out  by  a  curved 
incision  beginning  and  ending  at  the  same  points  as  the  first 
and  crossinc:  the  sole  near  the  orio-in  of  the  toes.  The  dor- 
sal  skin  flap  is  then  dissected  back  to  the  line  of  the  articu- 
lation, the  tendons  and  muscular  fibres  of  the  short  extensor 
divided,  the  joints  between  the  fifth,  fourth,  and  third  meta- 
tarsals, and  the  corresponding  bones  of  the  tarsus  opened 
successively  from  the  outer  side,  and  that  between  the  first 
metatarsal  and  first  cuneiform  from  the  inner  side.  With 
the  point  of  the  knife  directed  transversely  across  the  dorsal 


M  KDIO-TAKSAL    OK    C  II  ()  T  A  H 'I' '  S   ()  1' K  li  A 'I' I  (J  N  .        Ill 


aspect  of  tho  l)asc'  of  tlie  second  metatarsal,  tlic  joint  l)ctwecn 
that  bone  and  the  second  cuneiform  is  soii;^]it  from  heiow 
npward.  and  after  it  has  heen  found  and  opened  the  inter- 
osseous li<r;iments  uniting  the  second  to  tlie  first  and  third 
metatarsals  are  divided  by  tlirusting  the  point  of  the  knife 
well  down  between  tliem,  the  fiat  of  its  blade  being  held 
parallel  to  the  long  axis  of  the  foot, 
and  tlie  toes  being  forcibly  depressed.  ^'^o-  '>!• 

After  tlie  bone  has  been  thus  dis- 
engaged, the  knife  is  passed  through 
the  articulation,  and  the  plantar  flap 
cut  from  within  outAvard. 

Modifications. — The  plantar  flap 
nuiy  be  cut  (1)  from  without  in- 
ward, or  (2)  by  transfixion,  before 
the  articulations  have  been  opened. 
Instead  of  disarticulating  it,  the  base 
of  the  second  metatarsal  may  be  cut 
oft*  with  pliers  or  a  saw  ancl  left  in 
place.  Hey  sawed  off"  the  projecting 
part  of  the  first  cuneiform  after  dis- 
articulating, but  this  weakens  the 
attachment  of  the  tibialis  anticus,  a 
disadvantage  which  is  not  offset  by 
the  improvement  in  the  outline. 


MEDIO-TARSAL  OR  CHOPART  S 
AMPUTATION. 


^-,,  .  ...  A.  Lisfianc's  amputation. 

Ihis  name  is  given  to  the  opera-     b.  chopart's  amimtation. 
tion   of  disarticulation   throuirh   the 

joints  formed  by  the  astragalus  and  calcaneum  behind,  the 
scaphoid  and  cuboid  in  front.  The  guides  to  the  joint  are 
the  tubercle  of  the  scaphoid  on  the  inner  side  of  the  foot, 
the  head  of  the  astrasjalus  on  the  dorsum,  and  the  anterior 
end  of  the  calcaneum  on  the  outer  border.  Tlie  first  named 
is  one-eighth  of  an  inch  in  front  of  the  articulation,  and  is 
the  first  bony  prominence  felt  on  drawing  the  finger  from 
the  inner  malleolus  forward  along  the  side  of  the  foot ;  the 


112 


AMPUTATIONS. 


sliarp  edge  of  the  second  can  be  readily  felt  when  the  ante- 
rior portion  of  the  foot  is  forcibly  depressed  ;  the  latter  can 
usually  be  made  out  by  adducting  the  toes  and  inverting  the 
sole,  nearly  midway  between  the  tip  of  the  external  mal- 
leolus and  the  base  of  the  fifth  metatarsal  bone,  or  nearer  the 
latter.  When  the  foot  is  at  rio-ht  angles  with  the  les:,  the 
anterior  articular  surfaces  of  the  astragalus  and  calcaneum 
are  in  the  same  plane,  one  crossing  the  foot  transversely  at 
the  points  indicated. 

Operation.     (Figs.  61,  62,  63.) — The  surgeon  places  the 
thumb  and  forefinger  of  his  left  hand  upon  the  tubercle  of 

Fig.  62. 


Outer  side     A    (hoparf  r-  amputatiuii.     B.  Syme's  amputittion      C.  Line  of  section  of  the 
bones  in  Syme's  amputation.     D.  Siibastragaloid  amputation. 


the  scaphoid  and  the  lower  and  outer  border  of  the  cuboid, 
with  the  palm  against  the  sole,  and  makes  a  curved  incision 
from  one  to  tlie  other  passing  an  inch  anterior  to  the  head 
of  the  astragalus,  and  terminating  on  each  side  just  below 
the  level  of  the  joint.  The  plantar  flap  is  next  marked  out 
by  an  incision  beginning  and  ending  at  the  same  points  as 
the  first,  and  crossinor  the  sole  of  the  foot  four  or  five  finorer- 
breadths  nearer  the  toes.  The  dorsal  flap  is  next  dissected 
up,  the  joint  entered  at  either  of  the  points  mentioned  as 
guides  (preferably  between  the  astragalus  and  scaphoid  on 
the  inner  side,  after  dividing  the  tendons  of  the  tibiales). 


SUlJ-ASTRAQALOIl)    AMPUTATION 


113 


opciKMl  ^vi(l(']y  by  dividing  tlic  dorsal  and  interosseous  liira- 
ments  and  depressing  tlie  toes,  and  tlie  plantar  !lap  cut  from 
Avithin  outward. 

Synie  })referred  to  make  the  plantar  llap  by  transfixion 
before  disarticulating. 

The  anterior  tendons  should  be  stitched  with  catt^ut  to 
the  deep  tissues,  and  the  dressing  should  keep  the  foot  in 
extreme  dorsal  ilexion  at  the  ankle  in  order  that  these  ten- 
dons may  so  unite  with  the  stump  that  their  nmscles  will 
prevent  the  heel  from  being  raised  by  the  unopposed  action 
of  the  muscles  of  the  clilf. 


SUB-ASTRAGALOID  AMPUTATION. 


(Figs.  62,  i),  and  63,  C.)- — The  guides  to  this  operation 

are  the  tip  of  the  external  malleolus  and  the  head  of  the 

The  joint  must  be  entered  from  in  front  on  the 


astragalus 


Fig.  63. 


Inner  side.    A.  Chopart's  amputation.     B.  Sj'me's  amputation.     C.  Suluuitragaloid 

amputation. 


fibular  side,  and  the  strong  interosseous  ligament  which  forms 
the  key  to  the  articulation  must  be  divided  step  by  step  from 
before  backward  and  inward.  The  posterior  tibial  vessels 
lie  behind  the  inner  malleolus,  and  must  be  carefully  avoided. 

10* 


,114  AMPUTATIONS. 

Bc'frinninir  at  the  outer  side  of  the  heel,  nearly  an  incli 
below  the  tip  of  the  external  malleolus,  an  incision,  extend- 
ing through  to  the  bone,  is  carried  straight  forward  to  the 
base  of  the  fifth  metatarsal  bone ;  thence,  curving  forward, 
across  the  dorsum  of  the  foot  to  the  base  of  the  first  meta- 
tarsal ;  thence  obliquely  backward  and  outward  across  the 
sole  of  the  foot  and  around  its  outer  border,  rejoining  the 
first  and  horizontal  part  of  the  incision  at  the  calcaneo- 
cuboid articulation.  The  soft  parts  must  be  separated  from 
the  outer  surface  of  the  calcaneum  and  cuboid  with  division 
of  the  peroneal  tendons,  the  dorsal  flap  dissected  back  to 
the  head  of  the  astragalus,  and,  on  the  inner  side,  beyond 
the  tubercle  of  the  scaphoid,  thus  dividing  the  tendon  of 
the  tibialis  anticus  and  the  anterior  portion  of  the  internal 
lateral  ligament.  The  interosseous  ligament  can  then  be 
easily  reached  by  depressing  the  toes,  passing  the  knife  be- 
tween the  astragalus  and  scaphoid,  and  cutting  backward 
and  inward  along  the  under  surface  of  the  fomier.  The 
soft  parts  on  the  inner  side  are  then  separated  from  the  cal- 
caneum, injury  to  the  vessels  being  avoided  by  keeping  close 
to  the  bone,  between  it  and  the  tendon  of  the  flexor  com- 
munis, the  foot  depressed,  and  the  tendo  Achillis  divided. 
This  last  is  a  very  difficult  part  of  the  operation,  and  great 
care  must  be  taken  to  keep  the  edge  of  the  knife  close  to 
the  bone  so  as  not  to  cut  through  the  skin. 

The  posterior  tibial  nerve  should  be  dissected  out  and  cut 
off"  as  high  up  as  possible,  so  that  it  shall  not  be  pressed 
upon  in  the  stump. 


AMPUTATION  AT  THE  AXKLE-JOINT. 

Same's  Amputation^  Tibio-tarsal  Ainjjutotion.  (Figs. 
62,  63,  B.) — Amputation  through  the  ankle-joint  by  the 
circular  method,  lateral  flaps,  or  a  long  anterior  flap  taken 
from  the  dorsum  of  the  foot,  as  proposed  by  Baudens,  did 
not  meet  with  favor,  because  the  delicacy  of  the  coverings 
or  the  vicious  position  of  the  cicatrix  rendered  the  stump 
practically  useless ;  and,  although  occasional  successes  were 
reported,  the   choice  still  lay  between   Chopart's  operation 


AMPUTATION    AT    THE    ANKLE-JOINT.         115 

and  amputation  of  the  Irg,  until  Prof.  Syme,  in  1S4-J,' 
showed  how  the  excellent  plantar  tla])  could  he  ohtaincd. 
Ahout  the  same  time  Jules  Koux,  of  Toulon,  met  the  same 
indication  bv  means  of  a  large  internal  lateral  flap  carried 
across  the  plantar  aspect  of  the  heel. 

By  greatly  restricting  the  necessity  for  amputation  of  the 
leg  this  o})eration  has  become  one  of  the  most  important 
and  frequently  performed  of  all  amputations.  The  objec- 
tions urged  against  it,  and  the  unfavorable  results  that  have 
sometimes  followed  its  use,  seem  to  have  had  their  origin  in 
a  failure  to  understand-  or  carry  out  all  the  details  of  its 
execution,  or  in  the  introduction  of  improper  modifications. 
It  has  seemed  desirable,  therefore,  to  reproduce  here  Prof. 
Syme's  directions  for  performing  it,  as  published  in  1848," 
six  years  after  he  had  first  put  it  into  practice. 

'•  Succeeding  experience  taught  me  that  a  much  smaller 
extent  of  fiap  than  had  oriixinallv  been  considered  necess;irv 
was  sufficient  for  the  purpose,  and  that  hence  the  operation 
could  not  only  be  simplified  in  perfornianee.  but  increased 
in  safety  from  bad  effects. 

'-  The  foot  being  placed  at  a  right  angle  to  the  leg,  a  line 
drawn  from  the  centre  of  one  malleolus  to  that  of  the  other, 
directly  across  the  sole  of  the  foot,  will  show  the  proper 
extent  of  the  posterior  flap.  The  knife  should  be  entered 
close  up  to  the  fibular  malleolus,^  and  carried  to  a  point  on 
the  same  level  of  the  opposite  side,  which  will  be  a  little 
below  the  tibial  malleolus.  The  anterior  incision  should 
join  the  two  ppints  just  mentioned  at  an  angle  of  45°  to  the 
sole  of  the  foot,  and  long  axis  of  the  leg.  In  dissecting  the 
posterior  flap,  the  operator  should  place  the  fingers  of  his 
left  hand  upon  the  heel,  while  the  thumb  rests  upon  the  edge 
of  the  integuments,  and  then  cut  between  the  nail  of  the 
thumb  and  tuberosity  of  the  os  calcis,  so  as  to  avoid  lacer- 
ating: the  soft  parts  which  he  at  the  same  time  ijentlv.  but 
steadily,  presses   back    until    he   exposes  and   divides  the 

^  Lond.  and  Edin.  Monthly  Journ.  of  ^led.  Science,  Feb.  1S43. 

'  Contributions  to  the  Path,  and  Practice  of  Surijerv.  Ediuburs^h, 
1848. 

'  "The  tip  of  the  external  malleolus,  or  a  little  posterior  to  it; 
rather  nearer  the  posterior  than  the  anterior  margin  of  the  bone." — 
Syme,  in  Lancet,  1850. 


116  AMPUTATIONS. 

tendo  Achillis/  The  foot  should  be  disarticiihited  before 
the  malleolar  projections  are  removed,  -which  it  is  always 
proper  to  do,  and  which  may  be  most  easily  effected  by 
passing  a  knife  round  the  exposed  extremities  of  the  bones 
and  then  sawing  off  a  thin  slice  of  the  tibia  connecting  the 
two  processes." 

Disarticulation  is  accomplished  by  opening  the  joint  in 
front  and  dividing  the  lateral  ligaments  by  entering  the 
point  of  the  knife  between  the  sides  of  the  astragalus  and 
the  malleoli. 

The  essentials  of  the  method,  as  pointed  out  by  the  more 
recent  Scotch  writers  (Lister,  Spence,  and  Bell),  are  that 
the  plantar  incision  should  run  from  the  tip  of  the  external 
malleolus  directly  across  the  heel,  should  on  no  account  in- 
cline forward,  and  should  terminate  at  least  half  an  inch 
below  the  tip  of  the  internal  malleolus  (behind  and  below, 
according  to  Lister).  In  case  the  heel  is  unusually  long 
the  incision  may  even  incline  backward.  It  is  not  only 
unnecessary,  but  actually  dangerous,  to  make  the  flap  longer 
than  this,  for  it  then  becomes  impossible  to  dissect  out  the 
calcaneum  without  scoring  the  subcutaneous  tissue  in  all 
directions,  and  increasing  the  chances  of  sloughing.  If  the 
incision  is  made  further  back  and  carried  any  higher  on  the 
inner  side,  the  posterior  tibial  will  be  cut  before  its  division 
into  the  two  plantar  arteries. 

Erichsen  and  Lister  both  claim  that  the  integrity  of  the 
posterior  tibial  is  not  of  great  importance,  the  vitality  of 
the  flap  depending  mainly  upon  anastomosing  branches  of 
high  origin  which  lie  quite  near  the  bone.  Erichsen^  calls 
attention  to  the  existence  of  a  "branch  of  considerable 
size  w^hich  arises  from  the  posterior  tibial  artery,  about  one 
and  a  half  to  two  inches  above  the  ankle-joint,  and  passes 
down  to  the  inner  side  of  the  os  calcis,"  communicating 
freely  above,  below,  and  behind  this  bone  with  the  peroneal 
artery  on  the  other  side.  As  these  anastomosing  loops  lie 
much  nearer  the  bone  than  the  skin,  great  numbers  of  them 
will  be  divided,  and  the  vitality  of  the  flap  endangered,  un- 

1  It  is  now  generally  considered  better  to  divide  the  tendon  from 
above  downward,  after  disarticulating,  keeping  the  edge  of  the  knife 
close  to  the  upper  and  posterior  aspect  of  the  bone. 

2  Science  and  Art  of  Surgery,  vol.  i.  p.  77.     Lea,  Phila.,  1873. 


AMPUTATION    AT    TIIK    A  N  K  L  K -,J  ()  I  N  T  .  117 

less  the  {'(l^o  of  llic  kiiilc  is  kc'})t  close  against  the  hoiic 
(luring  the  disseetioii.  Jiister  goes  so  far  as  to  say  that 
sloughing  of  the  ihip  is  always  the  fault  oF  the  surgeon,  and 
r>ell  intimates  the  same  thing. 

lioux'  has  shown  that  this  close  dissection  is  not  witiiout 
its  daniT:ers  from  the  other  side.  In  two  of  his  cases  osteo- 
})hytes  developed  within  the  stump  from  portions  of  the 
])eriosteum  left  adherent  to  the  Hap.  The  autopsy  in  one 
of  these  eases  shoAved  that  six  osteophytes  had  formed  and 
become  carious  within  a  year  after  the  operation. 

A  short  longitudinal  'incision  through  the  dcej)  ])arts  along 
the  middle  of  the  plantar  aspect  of  the  calcaneum  will  some- 
times render  this  step  of  the  operation  easier,  and  be  less 
disadvantageous  than  the  employment  of  great  force. 

Modifications.  A.  Internal  Lateral  Flap. — When  the 
outer  side  of  the  foot  has  been  so  altered  by  injury  or  dis- 
ease that  the  heel  flap  cannot  be  obtained,  a  very  good  sub- 
stitute may  be  had  in  the  large  internal  flap  suggested  by 
Jules  Roux,  and  adopted  with  slight  changes  by  Sedillot, 
Mackenzie,  and  others.  Prof.  Spence  says  this  stump  can 
hardly  be  distinguished  from  Syme's. 

An  incision  (Fig.  64)  is  commenced  at  the  outer  side  of 
the  tendo  Achillis,  a  little  above  its  insertion,  carried  straight 
forward  under  the  outer  malleolus,  then  in  a  curved  line 
across  the  instep  half  an  inch  in  front  of  the  anterior  articu- 
lar edge  of  the  tibia,  and  backward  to  a  point  just  in  front 
of  the  inner  malleolus ;  thence  directly  downward  to  the 
sole,  across  it  obliquely  backward  to  its  outer  border,  and 
then  backward  and  upward  around  the  heel  to  the  point  at 
which  it  began.  The  edges  of  the  flaps  are  next  dissected 
up  for  a  short  distance,  the  joint  entered  at  the  outer  side, 
and  the  internal  flap  completed  from  within  outward  after 
disarticulation. 

Sedillot's  modification  of  this  consists  in  making  the  flap 
more  quadrilateral  than  triangular,  by  a  semicircular  incision 
across  the  dorsum  three  finger-breadths  in  front  of  the  mal- 
leoli, and  by  carrying  the  posterior  end  of  the  external  hoi-i- 
zontal  incision  across  the  tendo  Achillis  to  its  inner  border. 

^  Bull,  de  la  Soc.  de  Chirurgie,  torn.  iii.  p.  491,  1853. 


118 


AMPUTATIONS. 


Mackenzie's  method  differs  only  in  beginning  the  incision 
at  the  inner  border  of  the  tendon  and  a  little  higher  up. 

It  is  probable  that  a  serviceable  external  flap  could  be 
made  in  the  same  way,  although  its  vascular  supply  would 
be  scantier. 

B.  Pirogoff's  Anqmtation. — This  is  a  much  more  im- 
portant modification,  since  it  involves  not  merely  the  method 
of  performing  the  operation,  but  also  the  retention  of  the 
posterior  portion  of  the  calcaneum,  and  its  ultimate  union 

Fig.  64. 


Amputation  through  the  ankle-joint  by  large  internal  lateral  flap  (Roux). 

with  the  tibia.  The  only  additional  anatomical  point  that 
needs  mention  in  connection  with  it  is  that  the  long  axis  of 
the  calcaneum  is  directed  upward  as  well  as  forward. 

An  incision  (Figs.  65  and  QQ,  A)  is  made  from  the  tip 
of  the  inner  malleolus  to  a  point  a  little  above  and  in  front 
of  the  tip  of  the  outer  malleolus,  crossing  the  instep  half  an 
inch  in  front  of  the  anterior  edge  of  the  tibia.  A  second 
incision  crossing  the  sole  at  the  level  of  the  calcaneo-cuboid 
articulation  unites  the  extremities  of  the  first,  and  should  be 
carried  boldly  down  to  the  bone.  The  plantar  flap  is  then 
dissected  back  for  a  quarter  of  an  inch,  and  the  dorsal  flap 
to  the  edge  of  the  joint,  the  malleoli  well  exposed,  and 
the  joint  opened  widely  by  dividing  the  lateral  ligaments. 
By  drawing  the  foot  forward  and  depressing  it  a  narrow 


AMPUTATION    AT    THE    ANKLE-JOINT.         119 

rmtc-liers  or  a  chain  saw  can  be  passed  tliron^li  tlie  joint, 
and  ap})lied  to  the  Ciilcaneum  l)ehind  the  posterior  lip  of  the 
astratjahis,  and  the  bone  sawn  throu*di  downward  and  for- 

Fig.  05. 


PirogrofTs  amputation.     A.  Cutineous  incision  (outer  side).     B.  Line  of  section  of 

the  bones. 


Fig.  66. 


PirogrofTs  amputation.     ^4.  Cutaneous  incision  (inner  side).     B.  Parallel  soction  of 
the  bones  (Sedillot's  modification). 

ward  in  such  a  direction  that  the  section  will  tenninate  half 
an  inch  behind  the  lower  ed^re  of  the  calcaneo-cuboid  articu- 
lation.     The  malleoli  and  a  slice  of  the  tibia  are  then  re- 


120  AMPUTATIONS. 

moved  as  in  Syme's  operation,  and  enough  of  the  anterior 
anorle  of  the  calcaneum  removed  to  make  the  length  of  its 
surface  of  section  correspond  with  that  of  the  tibia.  Some 
surgeons  prefer  to  reverse  this  order,  and  remove  the  mal- 
leoli before  sawinof  throuo;li  the  calcaneum.^ 

The  cut  surface  of  the  calcaneum  must  then  be  brouofht 
up  against  that  of  the  tibia,  and  if  the  section  of  the  former 
has  been  suflSciently  oblique,  and  has  commenced  far  enough 
back,  this  can  be  done  without  making  excessive  tension  upon 
the  tendo  Achillis,  otherwise  another  slice  must  be  removed 
from  one  of  the  bones  or  the  tendon  divided  subcutaneously. 
Suturing  together  of  the  bones  has  been  occasionally  tried, 
as  has  also  fastening  them  together  by  a  long  steel  pin 
driven  through  the  skin  of  the  sole  and  the  calcaneum  into 
the  tibia. 

Several  modifications  of  this  operation  have  been  sug- 
gested, but  they  can  hardly  be  considered  as  improvements. 
Vertical  division  of  the  calcaneum,  as  originally  proposed 
by  Pirogoff  and  Ure,^  deprives  the  stump  of  the  advantages 
of  the  heel  pad  by  swinging  the  latter  too  far  forward,  and 
bringing  the  weight  of  the  body  upon  the  thinner  skin  cover- 
ing the  insertion  of  the  tendo  Achillis.  It  also  causes  undue 
tension  of  the  tendon  when  the  bones  are  brought  together. 
Sedillot  suggested  an  oblique  section  of  the  tibia  upward 
and  backward,  parallel  to  that  of  the  calcaneum  (Fig.  66, 
B).  This  avoids  any  stretching  of  the  tendon,  and  insures 
a  well-placed  pad  under  the  heeL  but  it  shortens  the  limb 
somewhat,  and  places  the  point  of  support  behind  the  axis 
of  the  leg.  Pasquier  saws  both  tibia  and  calcaneum  hori- 
zontally; this  is  difficult  of  execution,  endangers  the  flap, 
and  also  leaves  the  point  of  the  heel  too  far  back.  The  sug- 
gestion which  is  occasionally  made  to  retain  the  malleoli 
is  unsurgical  and  unprofitable, — unsurgical,  because  union 
between  two  cut  surfaces  of  cancellous  bone  is  speedier, 
stronger,  and  not  exposed  to  greater  risks  than  when  one 

^  Pirogoft^'s  incisions  were  nearly  identical  with  Syme's.  He  also 
divided  the  calcaneum  vertically,  and  left  in  the  articular  surface  of 
the  tibia  unless  it  was  diseased. 

2  Ure's  conception  of  the  operation  seems  to  have  been  original  with 
him.  His  case  was  published  in  the  Lancet  about  the  time  of  the 
appearance  of  Pirogoff's  book  at  Leipzig,  1854. 


AMPUTATION    OF    THE    LEG.  121 

surface  is  covered  witli  articular  cartilage:  unprofitalde.  be- 
cause notliing  is  gained  in  accuracy  of  adjustment  or  length 
of  limb. 

CohiparisoH  of  tlw  Different  Methods  of  Purthil  and 
Total  Amputation  of  the  Foot. — As  an  offset  to  the  advan- 
tage of  their  less  extensive  mutilation,  Lisfranc's  and  Cho- 
})art's  ani])Utations  are  open  to  the  objection  that  the  unop- 
posed action  of  the  muscles  of  the  calf  may  raise  the  heel 
permanently,  and  bring  the  weight  of  the  body  upon  the  end 
of  the  stump  and  the  cicatrix  ;  and,  furthermore,  when  these 
amputations  have  been  performed  for  disease  of  the  bones, 
those  bones  whieh  were  left  behind,  even  if  entirely  healthy 
at  the  time  of  the  operation,  have  ultimately  become  affected. 

Syme's  amputation  gives  an  excellent  stump,  and  the 
shortening  of  the  limb  is  no  more  than  is  necessary  to  per- 
mit the  adaptation  of  an  artificial  foot  and  a  spring  under 
the  heel,  but  it  is  comparatively  difficult  of  execution,  and 
the  flap  is  liable  to  pouch  and  favor  retention  of  the  pus. 
Piroiroft  "s  method  is  easier  of  execution  and  mves  a  lonixer 
limb,  but  an  artificial  foot  cannot  be  fitted  to  it  so  advanta- 
geously, and  in  cases  of  amputation  for  disease  it  is  contrary 
to  sound  principles  of  surgery  to  leave  in  the  stump  any 
bone  which  is  apt  to  become  subsequently  affected  :  it  brings 
the  heel  pad  a  little  too  far  forward,  and  requires  a  longer 
time  for  recovery  from  the  operation.  The  subastragaloid 
disarticulation  gives  a  longer  limb  and  a  good  stump,  but 
disease  is  very  apt  to  recur  in  the  astragalus. 

(See  also  Mickulicz's  osteoplastic  excision  of  the  leg.) 


AMPUTATIOX  OF  THE  LEG. 

A.  Lower  Third. — This  may  be  done  by  the  pure  cir- 
cular or  by  a  modified  circular  method,  with  a  long  anterior 
flap  made  to  overhang  the  square-cut  posterior  segment  of 
the  limb,  or  with  a  long  elliptic  posterior  flap,  including  the 
whole  of  the  tendo  Achillis.  The  two  former  result  in  a 
central  adherent  cicatrix ;  in  all  the  coverings  are  liable  to 
be  thin  and  tender,  and  the  artificial  limb  must  be  so  ad- 
justed that  the  weight  will  be  received  by  the  sides  of  the 

11 


122 


AMPUTATIONS 


leg  and  not  upon  the  face  of  tlie  stump.     The  compensatoi-y 
advantaores  are  that  the  control  of  the  limb  is  more  perfect 


Fig.  67. 


Fig.  G8. 


Fig.  07.— Amputatiou  of  leg.  A.  Modified  circiilar.  B.  Eectangular  flaps,  Teale. 
G.  Antero-posterioi  flaps,  upper  third,  Bell. 

Fig.  68.— Amputation  of  leg.  A.  Long  anterior  flap.  B.  Supra-malleolar  amputation 
by  long  posterior  flap,  Guyon.     C.  At  the  upper  third,  Sedillot. 


than  with  a  shorter  stump,  and   the  mortality  consequent 
upon  the  operation  less. 


AMPUTATION    Ol-^    THE    LEG.  123 

1.  Circular  3Iet] I  Oil. — A  circular  incision  is  made  tlii(uii;li 
the  skin,  and  a  cutaneous  sleeve  one  inch  lon«r  behind,  two 
inches  in  front,  is  dissected  \x\) ;  the  soft  parts  are  cut 
straight  through  to  the  boiu'  at  the  base,  and  then  retracted 
with  n  two-  or  three-tailed  hand,  according  to  the  breadtli  of 
tlie  interosseous  membrane,  and  the  bones  sawn  through, 
beginning  and  ending  with  the  tibia. 

'1.  Modified  Circular.  Fig.  07,  A. — Circular  incision 
through  the  skin,  met  by  a  liberating  longitudinal  one  on 
the  antero-external  aspect.  The  soft  parts  of  the  posterior 
portion  are  divided  rathCr  lower  than  those  of  the  anterior 
portion,  and  all  are  dissected  back  to  the  line  at  which  the 
bones  are  to  be  divided. 

Instead  of  a  single  liberating  incision  two  may  be  made, 
one  on  each  side;  and  then  by  rounding  off  the  corners  we 
may  have  double  skin  flaps  with  circular  division  of  the 
muscles,  the  "modified  flap"  operation. 

3.  Long  Anterior  Flajp  (Bell).  Fig.  68,  A. — An  ante- 
rior flap,  equal  in  length  to  the  diameter  of  the  leg  at  its 
base,  is  marked  out  by  a  curved  incision  through  the  skin, 
beginning  at  the  posterior  edge  of  the  tibia  on  the  inner  side, 
a  little  below  the  point  at  which  the  bones  are  to  be  divided, 
and  ending  at  a  point  directly  opposite  over  the  fibula.  The 
anterior  muscles  are  divided  transversely  half  an  inch  above 
the  lower  end  of  the  flap,  and  carefully  dissected  off"  the  bones 
and  interosseous  membrane  as  high  as  the  base  of  the  flap. 
The  separation  from  the  interosseous  membrane  should  be 
made  with  the  finger  or  handle  of  the  knife,  in  order  that 
the  anterior  tibial  artery  which  lies  immediately  upon  the 
membrane  may  not  be  injured.  The  posterior  flap  is  then 
made  by  transfixion  and  cutting  transversely  outward,  and, 
the  soft  parts  being  retracted,  the  bones  are  sawn  across  a 
little  higher  up. 

The  resulting  cicatrix  is  posterior  and  not  adherent  to  the 
end  of  the  bone.  BelP  reports  five  cases,  in  all  of  which 
there  was  complete  and  rapid  recovery,  with  a  useful  stump. 

4.  Elliptic  Posterior  Flap  (Guyon^).  Figs.  68  and  69, 
B. — The  incision  is  made  in  the  form  of  an  ellipse,  whose 
lower  end  crosses  the  heel  below  the  insertion  of  the  tendo 

^  Manual  of  Surg.  Operations,  3d  ed.,  p.  85.     Edinburgh,  1874. 
*  Bulletins  de  la  Society  de  Chirurgie,  1868,  page  337. 


124 


AMPUTATIONS. 


Fig.  09. 


Achillis,  and  whose  upper  end  is  about  an  inch  above  the 
anterior   articular    edge    of  the  tibia.      Beginning    at    the 

lower  end  and  dividing  the  tendo 
Achillis  at  its  insertion,  and  hugging 
the  bone  all  the  way,  the  flap  is  dis- 
sected up  posteriorly  as  high  as  the 
upper  end  of  the  ellipse.  The  ante- 
rior muscles  are  then  divided  by  trans- 
fixion, the  bones  sawn  through,  and 
the  posterior  tibial  nerve  resected. 

In  this  operation  the  sheath  of  the 
tendo  Achillis  is  not  opened,  and  the 
tendon  itself  serves  afterward  as  a 
covering  for  the  end  of  the  bone. 
The  retraction  of  the  muscles  of  the 
calf  tends,  in  course  of  time,  to  draw 
the  cicatrix  downward  and  backward, 
and  Faraboeuf  has  proposed  to  meet 
this  tendency  by  carrying  the  anterior 
end  of  the  ellipse  still  further  up  the 
leg,  so  that  that  part  of  the  incision 
through  the  skin  shall  be  an  inch  or 
so  above  the  line  of  division  of  the 
bones  and  anterior  muscles. 

B.  Middle  Third. — 1.  Long  an- 
terior curved  flap.  2.  Long  anterior 
rectangular  flap  (Teale).  3.  Long 
posterior  rectangular  flap  (Lee).  4. 
Simple  posterior  flap. 

1.  The  long  anterior  curved  flap 
is  made  according  to  the  method  de- 
scribed for  its  use  in  the  lower  third. 
Amputation  of  the  leg  and  at  Xhc  principal  poiuts  to  1  »e  bome  in 
the  knee.    A.  Long  posterior    ^-^^    .^^.^    ^^  Separate  the    anterior 

rectangular  flap,  Lee .   B  Supra-  in  i         • 

malleolar,  Guyon.    c.  At  the    musclcs  from  the  mtcrosscous  uicm- 
upper  third,  Sediiiot.    D.  Dis-    braue  with  the  finger  or  handle  of  the 

articulation  at  the  knee,  oval      j^^^jf^     ^^  ^^^^    ^|^^     n^  j^^^       eUOUgh 

to  fall  over  and  cover  the  broad 
posterior  surface  of  section  without  tension,  and  to  saw  off 
obUquely  the  prominent  angle  made  by  the  crest  of  the  tibia. 


AMPUTATION    OF    THE    LEG.  125 

2.  Lonj  Anterior  Jiecta)i</uliir  Flap  ('IV-alc).'  V\\i.  G7, 
B. — From  each  end  of  tlie  transverse  diameter  of  the  le^  at 
the  j)oint  at  whicli  the  l)one.s  are  to  })e  divided  an  incision, 
e(|ual  in  k'nt^th  to  lialf  tlie  circumference  of  tlic  le;^  at  tliat 
point,  is  made  do^^n^vard  and  sliglitly  backwai'd,  s<j  tliat  tlic 
two  shall  he  as  far  apart  at  their  lower  as  they  are  at  their 
upper  ends,  measuring  across  the  front  of  the  leg.  Their 
lower  extremities  are  then  united  hy  a  transverse  anterior 
incision  carried  through  to  the  bones  and  interosseous  mem- 
brane. The  flap  thus  marked  out  is  dissected  up  to  its  ba,se, 
the  sei)aration  from  th(i  interosseous  membrane  being  made 
with  the  finger  or  handle  of  the  knife  so  as  not  to  injure  the 
anterior  tibial  artery. 

A  posterior  fiap,  one-fourth  the  length  of  the  anterior 
one,  is  next  cut  by  a  transverse  incision  straight  down  to 
the  bones,  and  dissected  back  to  the  same  point,  the  inter- 
osseous membrane  divided,  the  bones  cleaned  and  sawn 
through. 

The  long  flap  is  then  doubled  back  upon  itself,  its  lower 
end  sewed  to  that  of  the  posterior  flap,  and  the  edges  of  the 
lateral  incisions  fastened  together. 

3.  Long  Posterior  Rectanfiular  Flap  (Lee).  Fig.  69, 
A. — The  incisions  are  similar  to  those  used  in  Teale's 
method,  but  they  involve  only  the  skin,  and  the  long  flap  is 
posterior,  the  short  one  anterior.  The  remainder  of  the 
operation  is  described  as  follows:^  "When  the  skin  had 
somewhat  retracted  by  its  natural  elasticity,  an  incision  was 
made  through  the  parts  situated  in  front  of  the  bones,  which 
were  reflected  upward  to  a  level  with  the  upper  extremities 
of  the  first  longitudinal  incisions.  The  deeper  structures 
at  the  back  of  the  leg  were  then  freely  divided  in  the  situa- 
tion of  the  lower  transverse  incision.  The  conjoined  gas- 
trocnemius and  soleus  muscles  were  separated  from  the 
subjacent  parts  and  reflected  as  high  as  the  anterior  flap. 
....  The  deeper  layer  of  muscles,  together  with  the  large 
vessels  and  nerves,  were  divided  as  high  as  the  incisions 
would  permit,  and  the  bones  sawn  through  in  the  usual  way. 
The  flaps  were  then  adjusted  in  the  manner  recommended 
by  Mr.  Teale. 

^  See  also  page  93. 

"^  Medical  Times  and  Gaz.,  June  3,  1865. 

11* 


126  a:mputatioxs. 

^'  The  long  flap  thus  formed  is  thicker  than  when  taken 
from  the  front  of  the  leg,  and  conseejuentlv  less  liable  to 
slough." 

In  muscular  subjects  and  when  amputating  high  up,  it  is 
sufl&cient  to  retain  the  gastrocnemius  alone. 

4.  Singh  Posterior  Flap. — When  the  muscles  have  be- 
come atrophied  a  single  posterior  flap  may  be  safely  made. 
A  transverse  incision  is  made  across  the  fi^ont  of  the  leg 
from  the  posterior  edge  of  one  bone  to  that  of  the  other, 
and  a  long  posterior  flap  cut  fi'om  within  outward,  by  trans- 
fixion. Its  length  should  be  equal  to  the  diameter  of  the 
leg  at  its  base. 

Q.  Upper  Third.  (-'Place  of  Election.'') — The  bones 
should  never  be  divided  above  the  attachment  of  the  liga- 
mentum  patellae  to  the  tuberosity  of  the  tibia,  and  it  is 
better  to  divide  two  inches  below  it.  when  possible,  so  as 
not  to  open  the  sheaths  of  the  flexor  muscles  of  the  thigh. 
Baron  Larrey  preferred  to  make  the  section  obliquely 
upward  and  backward,  beginning  at  the  middle  of  the 
attachment  of  the  ligamentum  patellae.  He  claimed  that 
this  could  be  done  without  opening  the  knee-joint,  and  that 
the  greater  vitality  of  the  spongy  tissue  made  recovery 
more  rapid.  The  head  of  the  fibula  should  not  be  removed, 
because  in  a  certain  proportion  of  cases  the  upper  tibio- 
fibular articulation  communicates  with  that  of  the  knee. 
The  circular  and  the  various  flap  methods  may  be  employed. 

1.  Circular. — At  a  distance  below  the  point  at  which 
the  bones  are  to  be  divided  one  inch  greater  than  half  the 
diameter  of  the  leg  at  that  point,  an  incision  involving  only 
the  skin  is  begun  upon  the  anterior  aspect  and  carried 
around  the  leg,  crossing  the  posterior  aspect  half  an  inch 
lower  than  in  front.  After  dissecting  the  skin  upward  for 
a  short  distance  the  gastrocnemii  and  part  of  the  soleus  are 
divided  transversely,  and  the  dissection,  including  the  parts 
thus  divided,  carried  up  to  the  line  of  division  of  the  bones, 
where  the  remaining  muscles  and  the  interosseous  mem- 
brane are  then  divided  transversely,  a  three-tailed  retractor 
applied,  and  the  bones  sawn  through. 

2.  The  lone  rectanorular  and  the  single  anterior  and 
posterior   flaps,  described   for   the   middle   third,   are  also 


COMPARISON    OF    DIFFERENT    METHODS.      127 

applicable  here.     The  directions  already  given  in  the  })re- 
ceding  section  are  sufficient. 

3.  External  Flap  (Sedillot).  Figs.  68  and  69,  C— Tlic 
])oint  of  the  knife  is  entered  a  finger's  breadth  external  to 
the  crest  of  tlie  tibia,  carried  backward  and  upward, 
grazing  the  fibula,  and  brought  out  posteriorly  as  far  to  the 
inner  side  as  possible,  and  at  a  point  an  inch  higher  than 
that  at  which  it  was  entered.  While  the  soft  parts  are 
drawn  toward  the  outer  side  with  the  left  hand,  a  gently 
rounded  flap,  four  finger-breadths  in  length,  is  cut,  and  its 
extremities  afterward  uiiite<l  bv  an  incision  slifrhtlv  convex 
downward,  across  the  front  and  inner  side  of  the  limb, 
involving  the  skin  only,  which  is  then  reflected,  and  the 
anterior  and  remaining  posterior  muscles  di\'ided  trans- 
versely at  its  base.  The  operation  is  completed  by  the 
division  of  the  bones  in  the  usual  manner,  and  bv  carefully 
stitching  the  edges  of  the  flaps  together,  leaving  the  pos- 
terior angle  open  for  drainage. 

4.  Modified  Flap  (Bell).  Fig.  67,  C. — Two  equal  semi- 
lunar flaps  of  skin  three  inches  long,  one  antero-extemal, 
the  other  postero-internal,  their  extremities  meeting  at  oppo- 
site points  about  two  inches  below  the  tuberosity  of  the  tibia. 
These  must  be  reflected  up,  and  with  them  another  inch  of 
skin,  embracing  the  whole  circumference  of  the  limb,  must 
be  dissected  up.  The  anterior  muscles  must  be  cut  as 
high  as  exposed,  and  the  posterior  ones  about  the  middle  of 
their  exposed  surface.  The  bones  must  then  be  sawn  as 
high  as  exposed,  the  fibula  being  finished  fii*st,  and  the  sharp 
prominence  of  the  edge  of  the  tibia  removed. 


COMPARISON  OF  THE  DIFFERENT  METHODS. 

Amputation  in  the  lower  thii'd  is  less  fatal  than  amputa- 
tion at  a  higher  point,  and  gives  better  command  of  the 
limb,  but  the  coverings  of  the  stump  are  liable  to  be  too 
thin  and  tender.  The  circular  and  double  flap  methods 
give  central  cicatrices  and  stumps  that  can  bear  no  weight 
upon  their  face,  and  are  sometimes  so  sensitive  that  even 
the  pressure  of  a  stocking  can  hardly  be  borne.  Guyon  s 
long  posterior  flap  taken  fi'om  the  heel  promises  well:  in 


128  AMPUTATIONS. 

the  first  case  reported  the  cicatrix,  six  weeks  after  the  ope- 
ration, was  two  inches  above  the  end  of  the  stump,  upon 
which  forcible  pressure  could  be  made  without  causing  any 
pain.^ 

The  long  anterior  flap  also  yields  a  cicatrix  which  is 
placed  posteriorly  and  out  of  the  way  of  pressure,  and  in 
short  it  may  be  said  that  the  reasons  which  made  the  upper 
third  the  place  of  election  have  lost  their  force  since  ampu- 
tation by  a  long  single  flap  has  been  shown  to  be  practicable 
at  any  point. 

In  the  middle  and  upper  thirds  Teale's  method  has 
proved  very  satisfactory,  but  it  requires  division  of  the 
bones  at  a  higher  point  than  is  necessary  in  the  single 
anterior  flap.  Lee's  modification  of  the  posterior  flap  has 
removed  the  dangers  due  to  the  redundancy  of  muscle  and 
the  presence  of  the  main  nerves  and  vessels  in  the  flap, 
while  careful  dressing  and  attention  to  posture  will  diminish 
or  entirely  remove  those  due  to  the  posterior  position  of  the 
flap  and  its  mechanical  defects. 

After  amputation  in  the  upper  third  the  weight  of  the 
body  may  be  borne  upon  the  tough  skin  below  the  patella, 
the  patient  kneeling  upon  his  artificial  leg;  or  the  stump 
may  fit  into  the  hollow  end  of  an  artificial  limb,  the  upper 
edse  of  which  will  receive  the  weio-ht  from  the  lower  edge 
of  the  patella  and  the  broader  bony  surfaces  near  the  joint. 
In  either  case  motion  at  the  joint  is  preserved,  and  there  is 
no  pressure  upon  the  cicatrix. 


AMPUTATIOX  AT  THE  KXEE. 

Under  this  head  are  ranged  pure  disarticulations  and 
amputations  through  the  condyles  of  the  femur.  In  dis- 
articulating, the  lateral  and  crucial  ligaments  should  be 
divided  near  their  attachments  to  the  femur,  and  the  semi- 
lunar cartilages  removed.     The  coats  of  the  popliteal  vein 

'  ^  In  a  letter  to  me,  dated  June,  1877,  Prof.  Guyon  slates  that  he 
has  amputated  four  times  by  this  method,  and  has  every  reason  to  be 
satisfied  with  the  result.  The  patients  bore  their  weight  upon  the 
stump  as  freely  as  upon  the  other  foot.  Two  cases  are  reported  in 
the  Bull,  de  la  Soc.  de  Chirurgie^  1877,  p.  321. — L.  A.  S. 


AMPUTATION    AT    TUE    KNEE.  129 

are  iiniisiially  tliick  and  stifl',  and  its  relations  to  tlic  artery 
are  so  intimate  that  tlie  }nilsati(»ns  of  the  hitter  are  liahh- 
to  l)e  conimunieated  to  it  and  to  lead  to  secondary  venous 
hemorrhage,  unless  the  two  vessels  are  separated  upward 
for  about  an  inch. 

A.  Disarticulation.  Oval  Method  (Baudens).  Y\<^. 
(J9,  I). — An  oval  incision  crossing  the  front  of  the  leg  five 
finger-breadths  below  the  end  of  the  patella,  and  the  back 
three  finger-breadths  higher  than  in  front,  is  made  through 
the  skin,  and  the  antei"ior  flap,  including  the  flexor  tendons 
on  the  inner  side  of  the  tibia  and  their  fibrous  connections, 
dissected  up  and  reflected  until  the  lower  end  of  the  patella 
is  exposed.  Then  flexing  the  leg  the  operator  divides  the 
ligament  innnediately  below  the  patella,  and  with  it  all  the 
anterior  part  of  the  capsule.  He  next  divides  the  lateral 
ligaments  and  then  the  crucial  ligaments,  taking  care  not  to 
injure  the  popliteal  vessels  with  the  point  of  his  knife. 

The  tiljia  is  then  drawn  forward,  the  knife  passed  through 
to  the  posterior  border  of  the  joint,  its  edge  directed  down- 
ward, and  the  remaining  soft  parts  divided  from  within 
outward. 

If  necessary  the  popliteal  artery  can  be  compressed  by  an 
assistant  in  the  flap  behind  the  knife  before  its  division. 

Long  Anterior  Flap.  Fig.  70,  A. — A  tongue-shaped 
flap  is  marked  out  by  an  incision  beginning  half  an  inch  be- 
low the  line  of  the  articulation  nearly  as  far  back  as  the 
posterior  border  of  the  condyle  on  one  side,  and  ending  at 
the  corresponding  point  on  the  other,  after  crossing  the  leg 
five  inches  below  the  patella.  A  transverse  posterior  in- 
cision unites  the  sides  of  the  first  an  inch  below  its  ends. 
The  flap  is  dissected  up  and  the  disarticulation  completed  as 
before. 

Prof.  Pancoast  has  modified  the  operation  by  making 
inside  of  a  single  short  posterior  flap  two  small  semilunar 
postero-lateral  ones,  meeting  in  the  centre  of  the  popliteal 
space. 

B.  Amputation  tiirouoii  the  Condyles.  Oval  3Ie- 
thod. — The  incision,  similar  to  that  used  for  disarticulation, 
ends  in  front  three  finger-breadths  below  the  patella,  and 
the  joint  is  opened  above  instead  of  below  this  bone,  which 


130 


AMPUTATIONS. 


is  not  included  in  the  flap.     After  disarticulation  has  been 
effected,  the  posterior    soft    parts    divided,  and   the  artery 

tied,  the  condyles  are  sawn  through 
Fig.  70.  above  the  edge  of  the  articular  car- 

tilage. Or  the  saw  may  be  applied 
Avithout  having  previously  disar- 
ticulated. 

Anterior  Flap  (Garden^).  Fig. 
70,  B. — "  The  operation  consists 
in  reflecting  a  rounded  or  semi-oval 
flap  of  skin  and  fat  from  the  front 
of  the  ioint :  dividinor  evervthino- 

•J  O  t  o 

else  straight  down  to  the  bone ; 
and  sawing  the  bone  slightly  above 
the  plane  of  the  muscles:  thus 
forming  a  flat-faced  stump  with  a 
bonnet  of  integument  to  fall  over  it. 
"The  operation  is  simple  and  is 
performed  easily  in  two  ways. 

"The  operator,  standing  on  the 
right  side  of  the  limb,  seizes  it  be- 
tween  his  left  forefinger  and  thumb 
at  the  spots  selected  for  the  base  of 
the  flap,  and  enters  the  point  of 
his  knife  close  to  his  finger,  bring- 
ing it  round  through  skin  and  fat 
below  the  patella  to  the  spot  pressed 
by  his  thumb ;  then  turning  the 
edge  downward  at  a  right  angle 
with  the  line  of  the  limb,  he  passes 
it  through  to  the  spot  where  it  first 
entered,  cutting  outward  through 
everything  behind  the  bone.  The 
flap  is  then  reflected,  and  the  re- 
mainder of  the  soft  parts  divided 
straight  down    to  the  bone;^    the 

muscles  are  then  slightly  cleared  upward,  and  the  saw  is 

applied. 


Amputation  at  the  kuee  and 
lower  third  of  thigh.  A  Disar- 
ticulation, long  anterior  flap  B. 
Amputation  through  the  condyles, 
Cardan.  C.  Modified  flap  ampu- 
tation at  the  lower  third  of  the 
thigh,  Svme. 


1  Britisli  Med.  Journal,  April  IG,  1864. 

'^  Lister  and  Bell  recommend  a  posterior  skin  flap  one  inch  long. 


AMPUTATION    AT    THE    KNEK.  131 

*'0r  tlio  tlji|)  iiiuy  be  ivllecte<l  first  and  the  knee  exam- 
ined, partieularly  if  tlie  operator  he  iin(h'ci«U-(l  hetween 
reseetion  and  am})Utati(»n.  In  anij)utatin^  throu^li  tlie  con- 
dyles, the  patelhi  is  drawn  down  by  flexing  the  knee  to  a 
riffht  anirle  before  dividin;^  the  soft  ])arts  in  front  of  the 
bone  ;  or  if  tliat  be  inconvenient  the  patella  may  be  reflected 
downward. 

''The  Hap  falls  easily  over  the  end  of  the  bone,  and, 
when  united  to  the  posterior  inteLrnments  by  a  few  pins  and 
sutures,  is  drawn  strongly  u})ward  and  backward  by  tlie 
greatly  retracted  flexors,  and  has  a  somewhat  puckered  and 
redundant  appearance  at  first.  .  .  .  Whatever  dressing 
be  used,  it  is  of  great  importance  to  loosen  it  and  examine 
the  stump  early,  and  to  provide  carefully  for  the  free  escape 
of  serum.  I  remove  the  pins  and  sutures  at  from  twenty- 
four  to  forty  hours  at  furthest." 

Gritti's  3Iodific((tio7i. — This  is  the  analofrue  of  Pirofroff  "s 
modification  of  Syme's  amputation  at  the  ankle.  The  articu- 
lar surface  of  the  patella  is  removed  and  the  cut  surface  of 
the  bone  applied  against  that  of  the  femur.  The  natural 
mobility  of  the  skin  over  the  patella  is  preserved,  and  the 
usefulness  of  the  stump  increased  thereby  ;  but  it  not  unfre- 
quently  happens  that  the  patella  is  drawn  upward  by  the 
quadriceps  femoris,  and  union  does  not  take  place  between 
the  two  bones.  Gritti  sawed  through  the  femur  at  the  upper 
edge  of  the  articular  surface.  Stokes  thinks  the  chances  of 
union  between  the  patella  and  femur  are  increased  by  saw- 
ing the  latter  three-quarters  of  an  inch  higher.  Yon  Lin- 
hart^  claims  that  the  stump  is  better  than  that  obtained  by 
amputation  in  the  lower  third  of  the  femur,  but  not  better 
than  that  obtained  by  disarticulation. 

A  rectangular  anterior  flap  (Fig.  71,  ^)  extending  from 
the  centre  of  the  condyles  to  the  tuberosity  of  the  tibia  is 
marked  out,  and  dissected  up  after  division  of  the  ligamen- 
tum  patella?  as  near  as  possible  to  its  insertion ;  the  skin 
covering  the  back  of  the  knee  is  divided  transversely,  or  by 
an  incision  curved  slightly  downward,  the  anterior  flap 
turned  back,  the  synovial  membrane  separated  from  its 
attiicliment  to  the  femur,  and  the  bone  sawn  through  well 

^  Compend.  v.  Operationslehre,  1867,  p.  401. 


132 


AMPUTATIONS. 


above  the  edge  of  the  articular  cartihige,  but  below  the 
medullary  canal.  The  remaining  soft  parts  are  then  divided 
from  within  outward,  and  the  vessels  secured.  The  articu- 
lar surface  of  the  patella  may  be  sawn  oft*  or  removed  with 


Fig.  71. 


A.  Gritti's  amputation  at  the  knee.  A'.  Lines  of  division  of  the  bone.  B.  Long  ante- 
rior flap  (Seel  illot).  B'.  Division  of  bone.  C.  Amputation  at  lower  third  (Spence).  C. 
Division  of  the  bono      D.  Disarticulation  at  the  hip. 

cutting  pliers,  and  this  step  in  the  operation  is  facilitated 
by  having  the  ligamentum  patellae  cut  long,  so  that  it  can 
be  used  to  hold  the  bone  firmly. 


AMPUTATION    OF    THE    THIGU.  133 


AMPUTATION  OF  THE  THIGH. 

The  central  pcsitiuii  i»f  the  lemur,  ami  the  abumlanee  of 
the  soft  parts  Iiave  made  it  possible  to  emj^loy  a  great  variety 
of  methods  of  amputation,  but  the  superiority  of  the  flaj) 
o])eration  is  now  generally  admitted,  with  certain  modifica- 
tions depending  ui)on  the  i)ortion  of  the  limb  selected  for 
amputation.  Thus,  in  the  lower  third  when  the  skin  over 
the  patella  is  uninjured,  Teale's  or  Garden's  method  is  to  be 
preferred ;  when,  on  th«i  other  hand,  that  portion  of  skin  is 
unavailable,  the  long  anterior  flap,  or  Syme's  modified  flap 
operation,  should  be  used ;  and  in  order  to  compensate  for 
the  greater  retraction  of  the  posterior  muscles  they  should 
be  cut  obliquely  insa-ad  of  transversely  in  the  former  ope- 
ration, and  on  a  lower  level  than  the  anterior  muscles  in  the 
latter.  In  the  middle  third  the  long  anterior  flap  is  to  be 
preferred.  Lateral  flaps  should  always  be  avoided  on  ac- 
count of  the  tendency  of  the  bone  to  project  at  the  upper 
angle,  drawn  forward,  as  it  is,  by  the  action  of  the  flexors 
of  the  thigh  upon  the  pelvis. 

The  muscles  are  more  abundant  on  the  inner  and  posterior 
aspects,  and  this  disproportion  increases  toward  the  hip. 
The  femoral  artery  will  be  found  in  the  posterior  flap  below 
the  middle  of  the  thigh,  in  the  anterior  flap  above ;  care 
must  be  taken  not  to  include  the  internal  saphenous  nerve 
in  the  ligature  placed  upon  it.  The  profunda  artery  lies 
close  behind  the  bone,  but  divides  early  into  it^  branches. 
The  sciatic  nerve  lies  between  the  short  head  of  the  biceps 
and  the  adductor  macrnus ;  it  should  be  drawn  crentlv  down- 
ward  and  divided  again  high  up. 

Sometimes  the  band  of  the  tourniquet  prevents  the  mus- 
cles from  retractinor  sufficiently  to  allow  the  bone  to  be 
cleared  to  the  proper  height.  Under  such  circumstances 
the  bone  should  be  divided  wherever  it  is  most  convenient, 
and  the  excess  sawn  off"  after  the  vessels  have  been  tied. 

Teale's  and  Garden's  methods  have  been  sufficiently  de- 
scribed.    (See  pp.  93.  130.) 

Modified  Flap  Operation  in  the  Lower  Third  (Syme). 
(Fig.  TO,  C.) — Two  equal  semilunar  flaps  of  skin  and  fat. 


184  AMPUTATIONS. 

one  anterior  tlie  other  posterior,  are  made,  raised  from  the 
fascia,  and  retracted  two  inches  further ;  "-  the  muscles 
should  then  be  divided  right  down  to  the  bone,  on  a  level 
as  high  as  they  are  exposed  in  front,  as  low  as  they  are 
exposed  behind."  The  bone  is  then  cleared  and  sawn 
through  two  inches  above  the  level  of  division  of  the  ante- 
rior muscles. 

Long  Antri'ior  Flap. — Sedillot/  vrriting  in  1854,  says 
he  has  used  this  method  exclusively  for  the  preceding  seven 
years.  Spence"  describes  a  method  as  first  practised  by 
himself  in  1858,  and  claims  that  his  '*flap  is  formed  on  a 
principle  essentially  different  from  that  which  regulates  the 
construction"  of  Sedillot's,  a  difference  which  is  not  recog- 
nizable in  the  descriptions,  the  length  of  the  flap  in  each 
case  being  equal  to  the  diameter  of  the  limb,  the  breadth  of 
its  base  "almost  two-thirds  of  the  circumference"  according 
to  Sedillot,  ''fully  equal  to  one-half  the  circumference" 
according  to  Spence,  and  the  muscle  contained  in  it  cut  ob- 
liquely by  both,  so  that  it  shall  not  be  too  thick.  Sedillot 
divides  the  posterior  segment  of  the  limb  transversely. 
Spence  divides  it  obliquely  fi'om  without  inward,  beginning 
two  inches  below  the  base  of  the  anterior  flap,  and  sometimes 
takes  an  additional  inch  of  skin,  a  difference  which  approxi- 
mates his  method  to  Teale's.  Benjamin  Bell  also  describes 
a  method  which  is  nearly  identical,  and  OHalloran  used  a 
similar  one  in  1765,  but  his  flap  was  too  short  to  accomplish 
its  purpose. 

Sedillot's  description  is  as  follows  (Fig.  71,  B) : 
The  flesh  of  the  anterior  aspect  of  the  limb  is  grasped  in 
the  left  hand,  and  an  incision  made  through  the  skin,  mark- 
ing out  a  flap  whose  length  is  equal  to  one-third,  and  its 
base  to  almost  two-thirds  of  the  circumference  of  the  limb. 
The  muscles  are  then  divided  obliquely  upward  and  back- 
ward so  that  the  flap  shall  not  be  too  thick,  the  posterior 
segment  of  the  limb  divided  transversely,  the  bone  cleared 
an  inch  or  two  hicrher  and  sawn  throucrh.  He  also  removes 
the  anterior  edge  of  the  bone  obliquely,  as  was  recommended 
for  the  tibia. 

^  Medecine  Operatoire,  2d  edition,  vol.  i.  p.  4:')o. 

'^  Lectures  on  Surgery,  2d  edition,  vol.  ii.  p.  G21,  Edinb.,  1876. 


AMPTTATION    AT    THE    HIP-JOINT.  135 

Spence  recommends  tlie  long  anterior  flap  as  especially 
applicabk'  to  amputation  in  the  lower  third,  and  he  makes 
it  as  low  as  possible,  so  that  its  lower  margin  is  on  a  level 
with  or  below  the  patella.  After  dissecting  up  the  skin  to 
the  upper  end  of  the  patella,  he  cuts  obliquely  upward 
through  the  anterior  muscles  to  the  bone  immediately  above 
the  condyles  (Fig.  71,  C).  While  the  soft  parts  are  re- 
ti*acte<l,  and  after  the  bone  has  been  cleared  circularly,  he 
elevates  the  femur  so  as  to  project  it  fully,  and  divides  it  two 
inches  above  the  base  of  the  flap. 


AMPUTATION  AT  THE  HIP-JOIXT. 

The  aflfections  which  render  this  most  serious  operation 
necessary  are  often  of  such  a  nature  that  the  surc'eon's 
choice  of  a  method  of  performing  it  is  greatly  restricted ; 
he  must  take  his  flaps  where  he  can  get  them,  and  must 
regulate  his  incisions  by  existing  lesions.  Moreover,  the 
problem  is  not  to  obtain  a  flap  that  will  bear  pressure,  but 
to  remove  the  limb  in  the  manner  that  involves  the  least  risk 
to  life.  This  risk,  which  has  proved  very  great,  is  due  not 
only  to  the  gravity  of  the  lesions  which  render  surgical  in- 
terference necessary,  but  also  to  three  causes  which  origi- 
nate in  the  operation  itself.  These  are  loss  of  blood,  shock, 
and  septiciemia :  the  fii-st  two  being  together  responsible 
for  about  as  many  deaths  as  the  third. 

The  opinion,  held  by  many,  that  the  amount  of  shock 
varied  directly  with  the  len^h  of  time  employed  in  remov- 
ing  the  limb,  led  to  the  introduction  of  operative  metho<ls 
characterized  by  extreme  rapidity  of  execution,  not  more 
than  thirty  seconds  being  allowed  for  the  removal  of  the 
limb  from  the  bo<ly ;  the  type  of  these  is  the  method  by  a 
long  anterior  flap  made  from  within  outward  by  transfixion. 

To  prevent  hemorrhage  many  ex])edients  have  been  em- 
ployed :  the  same  rapidity  of  execution  ;  compression  ot  the 
femoral  arteiy  upon  the  pubis,  or  within  the  flap  by  an 
assistant  who  passes  his  fingers  into  the  wound  behind  the 
knife;  compression  of  the  aorta:  preliminary  ligature  of  the 
femoral  artery:  ligature  of  each  vessel  when  encountered 
in  the  wound.     The   hemorrhacre  most  to  be  feared  is  that 


136  AMPUTATIONS. 

from  the  numerous  vessels  of  the  posterior  segment  of  the 
thigh,  for,  while  the  femoral  artery  can  usually  be  controlled 
without  much  difficulty,  there  is  no  way  of  preventing  the 
flow  of  blood  from  the  others  except  by  compression  of  the 
aorta  through  the  walls  of  the  abdomen,  or  of  the  internal 
iliac  throuo'h  the  rectum.  The  latter  device,  first  sufrajested 
as  a  means  of  hemostasis  during  operation  for  gluteal  aneu- 
rism, has  recently  been  employed  in  one  or  two  amputations 
with  success;  compression  of  the  aorta,  although  eifectual 
and  entirely  harmless  in  some  cases,  has  proved  dangerous 
or  impracticable  in  others^  by  exciting  peritonitis  or  inter- 
fering with  respiration. 

In  a  well-written  paper  read  before  the  Academie  de  Mede- 
cine,  30th  October,  1877,  Prof.  YerneuiP  reported  four 
disarticulations  at  the  hip-joint  performed  by  himself,  and 
expressed  himself  strongly  in  favor  of  ' '  operating  as  if  for 
the  removal  of  a  tumor,"  that  is,  by  cutting  from  without 
inward,  and  tying  each  vessel  when  it  is  encountered ;  by 
this  means  he  thinks  the  proportion  of  deaths  occurring 
within  the  first  few  hours  or  clays  as  the  result  of  hemor- 
rhage or  shock  (which  last,  by  the  way,  he  thinks  is  itself 
largely  the  result  of  hemorrhage)  could  be  greatly  dimin- 
ished. 

The  third  cause  of  fatal  results,  septicaemia,  was  thought 
by  Yerneuil  to  be  engendered  especially  by  the  retention 
of  decomposing  secretions  in  the  anfractuosities  of  the 
wound,  a  retention  which  the  ordinary  means  of  drainage 
cannot  prevent;  and  as  the  two  methods  of  dressing  wounds 
which  claim  to  prevent  decomposition  of  the  secretions, 
Lister's  and  Guerin's,  cannot  be  properly  applied  to  so 
short  a  stump,  Verneuil  sought  to  overcome  the  difficulty 
by  leaving  the  wound  open  and  not  placing  any  sutures,  in 
order  that  the  drainao-e  miojht  be  free,  and  also  bv  dressing 
the  wound  with  some  antiseptic.  For  the  sake  of  drainage 
he  rejected  the  anterior  flap  and  the  modified  oval  methods, 
and  gave  the  preference  to  the  lateral  flaps,  or,  still  better, 
the  so-called  "  anterior  oval,"  in  which  the  raw  surface  is 

1  See  Erskine  Mason,  Two  successful  Cases  of  Amputation  at  the 
Hip-joint,  iV.  Y.  Med.  Jour?i.,  Dec,  187G. 

2  Bulletin  de  I'Acad^mie  de  Medecine,  1877,  p.  1132. 


AMPUTATION    AT    THE    HlP-JOlNT.  137 

ilirt'cted  forward.  The  dres>iiig  was  as  follows:  1st.  a 
layer  of  small  pieces  of  tarlatan  covering  the  entire  raw 
surtace;.  -«L  a  thiek  layer  of  charpie  saturated  with  an 
antiseptic  solution,  alcohol,  carbolic  acid,  or  camphor ;  3d, 
a  layer  of  cotton  batting  covere<l  with  oil  silk,  and  a  simple 
retaining:  bandaije.  The  cotton  is  turned  back  several  times 
during  the  day,  and  the  lint  moistened  with  the  disinfecting 
solution. 

The  position  of  the  joint  may  l)e  determined  by  that  of 
the  anterior  inferior  spine  of  the  ilium,  which  is  three- 
quarters  of  an  inch  above  its  upper  margin. 

Anterior  Oval  JLtJiod  (VerneuiP). — The  patient  having 
been  anaesthetized  and  placed  upon  the  table,  an  Esmarch's 
elastic  band  is  applie<.l  from  the  toes  as  far  upward  as  is 
allowed  by  the  nature  of  the  lesion  and  the  line  of  the  pro- 
posed incision. 

1.  An  incision,  besrinnincr  a  finger's  breadth  below  Pou- 

o  o  c 

parts  ligament,  is  carried  down  along  the  course  of  the 
femoral  artery  for  about  two  inches  :  thence  outward  and 
downward,  crossing  the  great  trochanter  near  its  base,  to 
the  gluteal  fold :  thence  transversely  along  this  fold  to  the 
inner  side  of  the  thigh,  and  thence  obli<|Uely  upward  two 
full  finger-breadths  below  the  genito-crural  fold  to  the  point 
where  it  diverged  from  the  line  of  the  artery.  The  incision 
should  involve  only  the  skin  and  the  cellular  tissue ;  any 
vessels  that  are  divided  should  be  immediately  tied. 

2.  The  sheath  of  the  vessels  is  opened,  the  artery  isolated 
and  denuded,  and  its  point  of  biftircation  deteiTuined.  A 
ligature  is  then  applied  methodically  to  the  vessel  above 
the  origin  of  the  profunda,  and  a  second,  lower  down, 
including  both  branches  en  inasse,  and  the  artery  divided 
between  them.  The  femoral  vein  is  also  carefiillv  denuded 
and  divided  between  two  ligatures  at  about  the  same  level. 
Yerneuil  considers  the  ligature  of  the  femoral  vein  indis- 
pensable, but  it  must  be  done  with  the  utmost  care  and 
gentleness,  in  order  that  the  phlebitis  may  remain  limited  to 
as  small  a  portion  of  the  vessel  as  possible. 

3.  The  incision   is  carried  down   through    the   muscles, 

^  Bulletin  de  lAcademie  de  Medeciue,  1877,  p.  1159. 

12* 


138  AMPUTATIONS. 

beo-inning  on  either  the  outer  or  inner  side,  as  is  most  con- 
venient ;  on  the  inner  side,  after  having  cut  through  the 
adductors  at  the  junction  of  their  fleshy  and  tendinous  por- 
tions, seek  and  tie  the  obturator  vessels,  divide  the  pectineus 
and  psoas  on  a  line  with  the  neck  of  the  femur,  and  secure  all 
the  bleeding  points.  On  the  outer  side,  divide  the  sartorius 
and  the  fascia  lata,  and  then  adduct  the  thigh  so  as  to  throw 
the  great  trochanter  forward  and  facilitate  the  division  of 
the  muscles  attached  to  it. 

4.  Open  the  articulation  in  front  and  divide  the  posterior 
portion  of  the  capsule  as  close  as  possible  to  the  femur, 
together  with  the  remaining  tendons  that  are  inserted  in  the 
great  trochanter. 

5.  Division  of  the  posterior  segment  of  the  limb.  De- 
press the  thigh  beyond  the  border  of  the  table,  so  as  to 
make  the  wound  gape  widely,  and  divide  the  remainder  of 
the  adductors  and  the  muscles  attached  to  the  ischium  with 
gentle  strokes  of  the  knife,  tying  each  vessel  when  it  is 
recoo-nized  or  divided.  It  is  well  also  to  resect  the  extre- 
mity  of  the  sciatic  nerve. 

The  resulting  wound  is  conical  and  gapes  widely,  for, 
notwithstanding  the  laxity  of  the  tissues,  there  is  not  enough 
material  left  to  allow  the  sides  of  the  wound  to  be  brought 
together  without  undue  tension,  if  the  surgeon  should  wish 
to  do  so.  Verneuil  considers  this  a  positive  advantage,  for 
not  only  does  cicatrization  go  on  rapidly,  but  septicaemia  is 
less  likely  to  occur  in  a  well-exposed  wound  from  which  the 
secretions  escape  freely. 

Circular  Method. — The  patient  lying  upon  his  back  with 
his  thigh  overhanging  the  end  of  the  table,  a  circular  inci- 
sion is  made  through  the  skin,  six  inches  below  the  anterior 
superior  spine  of  the  ilium,  the  skin  retracted,  and  the 
muscles  divided  successively  at  higher  levels,  until  the  femur 
is  reached.  The  capsule  is  then  divided  in  front  and  on 
the  sides,  close  to  the  edge  of  the  cotyloid  cavity,  the  head 
of  the  femur  dislocated  forward,  the  knife  passed  behind 
it,  dividing  the  ligamentum  teres,  the  remainder  of  the  cap- 
sule, and  the  muscles  attached  to  the  neck  and  trochanter. 

Anterior  Flap. — The  position  of  the  patient  being  the 
same,  and  the  thigh  slightly  flexed  and  abducted,  the  point 


AMPUTATION    AT    THE    HIP-JOINT.  139 

of  a  long  amputtitiiig  knife  is  oiitcrcd  midway  between  tlie 
anterior  su})eri()r  spine  of  the  ilium  and  the  top  of  the  "-reat 
trochanter  and  j)assed  inward  and  backward  to  a  point 
one  inch  below  and  in  front  of  the  tuberosity  of  the  ischium, 
grazing  the  anterior  surface  of  the  neck  of  the  femur,  and 
certainly  opening  the  capsule  of  the  joint  if  its  edge  is 
kept  turned  obliquely  toward  it.  (The  direction  may  be 
reversed  for  the  right  thigh,  the  knife  being  entered  on  tlie 
inner  side.) 

A  well-rounded  flap  ending  at  the  junction  of  the  upper 
and  middle  thirds  of  the'  thigh  is  then  cut  with  rapid  saw- 
ing movements  of  the  knife,  and  reflected  upward.  The 
limb  is  forcibly  depressed,  and  if  the  capsule  has  been  well 
divided  this  movement  will  throw  the  head  of  the  femur 
forward  out  of  the  socket;  if  not,  a  single  cut  w^ith  the 
knife  across  the  head  of  the  bone  will  free  it.  The  leg  is 
then  rotated  inward  so  as  to  bring  the  trochanter  forward, 
the  surgeon  passes  the  knife  behind  the  head  of  the  bone 
and  cuts  a  short  posterior  flap  from  within  outward. 

Prof.  Van  Buren  divided  the  i)Osterior  segment  from 
without  inward  by  a  sweep  of  the  knife  as  in  a  circular 
amputation,  and  then  disarticulated  and  divided  the  rotator 
muscles  with  a  scalpel. 

In  the  flap  operation  by  transfixion  the  assistant  who 
compresses  the  artery  against  the  pelvis  with  one  hand 
should  follow  the  knife  with  the  other,  and  grasp  the  vessel 
in  the  flap  between  his  fingers  and  thumb,  and  his  control 
of  it  should  be  such  that  the  surgeon  can  give  his  attention 
first  to  securing  the  numerous  vessels  of  the  posterior  seg- 
ment, the  bleeding  from  which  may  be  partly  checked  by 
pressure  with  dry  sponges  or  cloths  while  the  ligatures  are 
being  applied.  Or  the  bleeding  points  may  be  caught  up 
rapidly  with  artery  forceps,  and  the  ligatures  not  applied 
until  after  all  have  been  thus  secured. 

Modified  Oval  Method.  Fig.  71,  D.— The  patient  is  laid 
upon  his  side,  his  hips  at  the  foot  of  the  table.  A  straight 
incision  three  inches  long;  is  begun  one  inch  above  the  sum- 
mit  of  the  great  trochanter,  and  carried  along  its  posterior 
border,  and  a  circular  incision  is  then  carried  from  the 
lower  end  of  the  first  around  the  thigh,  passing  three  inches 


140  AMPUTATIONS. 

below  the  tuberosity  of  the  ischium.  These  incisions  should 
interest  the  skin  only,  their  borders  should  be  dissected  up 
for  about  an  inch,  and  the  muscles  of  the  outer  aspect 
divided  obliquely  upward  toward  the  joint.  In  fi-ont  this 
division  should  not  be  carried  beyond  the  outer  edge  of  the 
rectus  muscle,  but  posteriorly  it  should  be  as  extensive  as 
possible  and  close  to  the  bone. 

The  thigh  being  flexed  and  adducted,  the  capsule  is 
opened,  first  longitudinally  on  the  finger  as  a  guide,  then 
forward  and  backward  along  the  edge  of  the  cotyloid  cavity, 
the  head  of  the  femur  dislocated  backward  and  outward,  the 
knife  passed  around  it  and  brought  down  along  the  inner 
side  of  the  bone  nearly  to  the  level  of  the  circular  incision, 
and  then  made  to  cut  its  way  rapidly  out  on  the  inner  side. 


PART    IV. 
EXCISION  OF  JOINTS  AND  ]30NKS. 


Excision  of  ;i  joint  may  be  (1)  complete  or  (2)  |)f/?'f^a/. 
In  the  former  case  the  articular  ends  of  all  the  Ijones 
composing  it  are  removed ;  in  the  latter,  one  or  more  are 
retained.  Auain,  jjartial  excision  may  consist  of  (1)  par- 
tial or  (2)  total  resection  of  the  articular  end  of  one  of  the 
members  of  the  joint.  The  former  is  ahvays  unadvisable ; 
the  latter,  to  -which  Oilier^  has  given  the  name  of  soni- 
artieular  resection^  has  given  good  results  in  traumatic 
cases,  and  of  late  also,  under  antiseptic  treatment,  in  tuber- 
culous affections  when  the  disease  is  still  restricted  to  a  por- 
tion of  the  bone  and  capsule. 

Excision  of  a  bone  may  be  total  or  partial,  and,  in  the 
case  of  the  long  bones,  with  or  without  either  or  both  epi- 
physes. 

The  term  resection  is  often  employed  as  a  synonym  of 
excision.  In  the  narrower  sense  it  refers  to  the  removal  of 
a  portion  of  a  bone,  including  however  its  entire  thickness ; 
thus,  a  joint  is  excised  by  the  resection  of  the  bones  com- 
j)osing  it. 

Joints  are  excised  on  account  of  injury,  disease,  or  an- 
chylosis in  a  faulty  position  ;  and  with  the  object  of  obtain- 
ing a  movable  joint,  as  in  the  upper  extremity,  or  anchylosis 
as  at  the  knee  and  ankle.  The  operative  procedures  may 
vary  with  these  causes  and  these  objects.  Thus,  when 
anchylosis  is  sought  for,  the  division  of  the  muscles  and 
tendons  about  the  joint  is  of  no  special  moment ;  but  if  the 
joint  is  to  be  reestablished,  the  muscles  which  control  its 
movements  must  not  be  disabled.     In  any  case  the  main 

1  Congres  Medical  de  France,  4th  session,  1872,  p.  224,  and  Bull, 
de  la  Soc.  de  Chirurgie,  1873. 


142  EXCISION    OF    JOINTS    AND    BONES. 

bloodvessels  and  nerves  must  be  respected ;  the  incisions, 
whenever  practicable,  should  be  parallel  to  the  long  axis  of 
the  limb  ;  and  when  it  is  necessarv  to  divide  a  tendon  or 
muscle,  the  line  of  section  should  be  oblique  rather  than 
transverse,  so  as  to  favor  reunion. 

The  incisions  should  be  sufficiently  free  to  allow  the  bone 
to  be  thoroughly  inspected  with  a  view  to  the  removal  of 
all  the  diseased  portion.  It  is  better  to  make  a  clean  divi- 
sion with  the  saw  than  to  remove  the  bone  piecemeal,  but 
the  use  of  the  gouge  is  proper  for  the  removal  of  small 
circumscribed  areas  of  disease  found  upon  the  surfaces  of 
section.     Rouo*heninoj  of  the  outer  surface  of  the  bone  due 

CO 

to  healthy  plastic  processes  must  not  be  mistaken  for  caries. 

The  synovial  membrane  in  traumatic  and  non-tuberculous 
suppurative  cases  does  not  require  special  attention ;  in 
tuberculous  cases  and  when  much  thickened  it  should  be  cut 
or  scraped  away  so  as  to  remove  such  foci  of  infection  as 
may  exist  within  its  wall  or  in  the  fungous  granulations  on 
its  surface.  When  anchylosis  is  sought  for,  as  at  the  knee, 
it  is  prudent  to  dissect  out  the  sac  entirely.  If  any  portion 
is  necessarily  left  the  destruction  of  the  foci  should  be  sought 
by  thorough  scraping,  washing  with  a  solution  of  chloride  of 
zinc,  1  to  30  or  40,  or  of  corrosive  sublimate,  1  to  1000,  or 
by  the  actual  cautery. 

The  propriety  of  retaining  the  periosteum  is  still  a  sub- 
ject of  discussion,  and  one  in  which  the  decision  will  pro- 
bably vary  with  the  articulation  and  the  circumstances  of 
the  case.  Certain  facts  have,  however,  been  already  estab- 
lished. Its  retention  is  a  safeguard  against  injury  to 
neighboring  tissues  during  the  operation  ;  after  excision  of 
a  bone  it  gives  firmness  to  the  cicatrix,  diminishes  the 
shortening  of  the  limb,  and  insures  the  proper  attachment 
of  the  muscles;  and  in  the  case  of  an  articulation,  if  its 
relations  with  the  capsule  are  maintained  (periosteo-capsular 
excision),  it  favors  the  reproduction  of  the  joint  Avith  arti- 
cular cartilages  and  ligamentary  support.  On  the  other 
hand,  the  reproduction  of  bone  is  not  always  desirable,  and 
may  be  excessive  or  irregular,  unduly  limiting  the  motions 
of  the  joint,  or  even  causing  anchylosis  ;  and  finally,  the 
bruising  received  by  the  periosteum  during  the  operation 


EXCISION    OF    JOINTS    AND    BONES.  143 

m.-iy  t'aiise  it  to  sl(»ii«^li,  or  the  reproduction  oi'  bono  inav  fail 
entirely. 

Von  Langenbeck^  luis  sliown  that  in  excision  of  the 
shoulder-joint  it  is  ot*  tlic  utmost  importance  to  preserve 
the  relations  of  the  })criosteum,  tlie  capsule,  and  the  tendons 
of  the  ca})sular  muscles,  but  in  all  other  joints,  except  per- 
haps the  hip,  tlie  importance  is  not  so  great,  or,  at  least,  so 
well  established.  Complete  restoration  of  the  shoulder- 
joint  and  reestablishment  of  the  control  of  the  muscles  over 
it  has  never  been  accomplished  except  by  the  subperiosteal 
method.  The  periosteum  can  be  removed  without  difficulty 
except  when  it  is  actively  inflamed ;  its  connection  with  the 
bone  is  very  slight  in  cases  of  chronic  osteitis  and  synovitis. 
The  tendons,  on  the  other  hand,  are  so  firmly  attached  to 
the  bone  that  the  elevator,  or  rugine,  is  sometimes  insuffi- 
cient to  remove  them  properly,  and  the  knife  must  then  be 
used,  its  edge  being  kept  as  close  as  possible  to  the  bone. 
Von  Langenbeck  goes  so  far  as  to  say  that  the  success  of 
a  periosteo-capsular  excision  depends  in  great  part  upon 
the  proper  alternation  in  the  use  of  the  knife  and  elevator. 

Vogt  and  Koenig  strongly  recommend  that,  instead  of 
separating  the  tendons  and  ligaments  from  the  bone,  the 
latter  should  be  cut  through  with  a  chisel  so  as  to  leave  a 
shell  attached  to  the  soft  parts.  In  children,  where  the  epi- 
physes are  still  cartilaginous,  this  section  can  be  made  with 
the  knife. 

Excision  of  single  bones  may  be  required  on  account  of 
injury  or  disease.  The  latter  is  by  far  the  most  common 
cause,  and  its  most  common  examples  are  caries  of  the  small 
spongy  bones  and  necrosis  of  the  long  ones  due  to  acute 
osteomyelitis  or  periostitis.  The  incisions  should  be  made 
from  the  side  where  the  coverings  of  the  bone  are  fewest 
and  of  least  importance ;  the  periosteum  should  be  left  be- 
hind, and  all  the  diseased  bone  should  be  removed.  When 
the  entire  shaft  of  a  bone  has  become  necrotic,  it  must  be 
divided  with  the  chain  saw  or  cutting  pliers,  and  each  piece 
pulled  or  cut  away  from  its  epiphysis. 

An  instrument  recentl}^  (1884)  invented  in  England,  and 
called  an  exsector  (Fig.  72),  promises  to  be  of  great  service 

*  Archiv  fiir  Klinische  Chirurgie,  vol.  xvi. 


144 


EXCISION    OF    JOINTS    AND    BONES 


as  a  substitute  for  tlie  keyhole  or  cliain  saw.     My  experience 
with  it  is  limited  but  very  favorable. 

The  term  evidemfnt  de  Ton  has  been  given  by  the  French 
writers  to  a  procedure  upon  which    Sedillot   attempted  to 


Fig.  72. 


Wyeth's  mndificatioD  of  Gowan's  exsertor 


establish  a  method  of  treatment.  It  consists  in  tlie  removal 
by  the  gouge  of  all  the  central  portion  of  a  carious  spongy 
bone,  an  epiphysis,  or  even  the  shaft,  leaving  only  the  pre- 
sumably hcnlthy  shell  attached  to  the  periosteum.  Although 


EXCISION    OF    THE    S  HOULDE  R- JOI  NT  .         145 

it  luis  provt'd   I'liulty  as  a  motliod,  it  is  a  useful  adjunct  lo 
excision. 

In  cutting  down  uixni  carious  bone  or  a  sequestrum  it  is 
well  to  keep  a  prol»c  in  the  sinus  leading  to  it,  as  it  is  some- 
times very  difficult  to  find  the  hole  in  the  bone  after  the 
blood  has  begun  to  How. 


MAJOR  ARTICULATIONS. 

EXCISION  OF  THE  SHOULDER-JOIXT. 

As  formerly  performed,  excision  of  the  shoulder-joint  was 
an  operation  the  results  of  wdiich,  to  quote  Holmes/  were 
'•probably  inferior — certainly  not  superior — to  those  of 
natural  anchylosis.*"  If  anchylosis  did  not  follow,  the  joint 
was  loose,  under  slight  control,  and,  at  the  best,  could  not 
be  raised  above  the  horizontal  line.  Oilier  and  Yon  Lan- 
genbeck,^  however,  have  shown  that  the  periosteo-capsular 
method  furnishes  a  much  larger  measure  of  success.  In  a 
case  operated  upon  by  the  former  where  four  inches  of  the 
humerus  was  removed,  the  ultimate  shortening  was  only  half 
an  inch,  and  the  motions  were  quite  full;  and  the  latter 
reports  several  cases  in  which  the  arm  could  be  raised  to  the 
vertical  line,  and  the  control  of  the  limb  was  perfect.  In 
all  of  Von  Langenbeck's  cases  the  operation  was  undertaken 
on  account  of  gunshot  injury. 

As  the  capsular  muscles  are  attached  to  the  greater  and 
lesser  tuberosities,  the  capsule  and  periosteum  must  be 
divided  between  these  two  bony  prominences,  that  is,  in 
the  direction  of  and  near  to  the  tendon  of  the  long  head  of 
the  biceps.  An  anterior  incision  beginning  at  the  acromio- 
coracoid  triangle  is  the  best  one  for  this  purpose,  and  has, 
moreover,  the  advantage  of  sparing  the  posterior  circumflex 
artery  and  nerve.  The  cephalic  vein  lies  in  the  groove 
between  the  deltoid  and  pectoral  muscles,  and  is  avoided 
by  making  the  incision    incline   outward.     When  the  soft 

1  Surgery,  its  Principles  and  Practice,  p.  929.    Lea,  Phila.,  1870. 
'  Traite  de  la  Regeneration  des  0$,  and  Des  Resections  des  Grandes 
Articulations.     ISOT. 

'  Archiv  fiir  Klinische  Chirurgie,  1874,  vol.  xvi. 

13 


146  EXCISION    OF    JOINTS    AND    BONES. 

parts  are  much  thickened  and  consolidated,  this  incision 
needs  to  be  snpi)lemented  by  a  short  transverse  one  (Fig. 
73,  B)  running  outward  from  its  upper  end  parallel  to  and 
just  below  the  edge  of  the  acromion,  dividing  the  fibres  of 
the  deltoid  transversely  in  its  course ;  sometimes  the  condi- 
tion of  the  parts  is  such,  and  the  sinuses  so  placed,  that  a 
large  external  flap,  with  its  base  directed  upward,  has  to 
be  made  by  a  triangular  or  curved  incision,  and  raised  up 
so  as  freely  to  expose  the  outer  aspect  of  the  head  of  the 
humerus.  In  any  case  the  trunk  of  the  posterior  circumflex 
artery  should  be  spared.  It  is  embedded  in  loose  cellular 
tissue,  and  wdien  cut.  may  retract  so  far  that  a  ligature  can- 
not easily  be  placed  upon  it. 

Fig.  73. 


Excision  of  the  !<huukler  (Oilier).     A  Kegular  incision.     B.  Supplementary. 

The  condition  of  the  glenoid  cavity  seems  to  aflect  the 
prognosis  seriously.  In  eight  fital  cases  collected  by 
Hodges,^  it  had  been  interfered  with  in  all  but  one.  Con- 
sequently it  should  not  be  touched  unless  actually  diseased, 
and  the  interference  should,  if  possible,  be  limited  to  the 
use  of  the  gouge. 

Spence  makes  a  counter-opening  behind  for  drainage, 
but  this  seems  to  be  unnecessary. 

Operation  (Oilier).  Fig.  73. — The  arm  is  abducted  and 
rotated  imvard.     The  point  of  the  knife  is  entered  at  the 

^  Excision  of  Joints,  Boston,  1801. 


EXCISION    OF    THE    SHOULDER-JOINT.         147 

Itrak  of  tlio  c-oracoid  process,  aii<l  cariMc*!  four  inclics  «lo\vii- 
wanl  and  outward  in  tlie  general  direction  of  the  fibres  of 
the  deltoid,  or  as  much  further  as  may  be  necessary.  The 
incision  thus  made  will  be  external  to  the  inner  border  of 
the  deltoid,  and  slmuld  comprise  all  the  tissues  down  to  the 
l»one. 

The  edges  of  the  wound  are  held  apart  with  retractors, 
and  the  eajtsule  and  periosteum  are  divided  along  the  outer 
e<lge  of  the  tendon  of  the  long  head  of  the  biceps  and  the 
bicipital  groove  to  the  fidl  extent  of  the  external  incision. 
The  outer  edge  of  tlie  incision  is  raised,  and  the  periosteum, 
together  with  the  capsule  and  tendons  of  the  muscles  inserted 
upon  the  greater  tuberosity,  is  carefully  detached  with  the 
elevator  and  knife,  while  an  assistant  rotates  the  arm  inward 
to  increase  the  extent  of  and  facilitate  the  dissection. 

The  tendon  of  the  biceps  is  then  raised  from  its  groove 
and  held  out  of  the  way,  the  arm  rotated  outward,  and 
the  periosteum,  capsule,  and  tendon  of  the  subscapular  dis- 
sected off  in  the  same  way  on  the  inner  si<le. 

The  head  of  the  humerus  is  then  dislocated  forward,  the 
posterior  attachments  of  the  capsule  separated  with  the 
elevator  or  knife,  the  periosteum  petded  off  the  posterior 
face  of  the  neck  and  shaft  of  the  humerus,  and  the  bone 
sawn  through  transversely  with  an  ordinary  or  a  chain 
saw. 

If  the  articular  surface  of  the  glenoid  cavity  is  affected, 
it  must  be  scraped :  if  the  bone  itself  is  diseased,  it  should 
be  souored  out  until  healthy  bleedincr  bone  is  reached,  or 
the  neck  may  be  cut  through  with  strong  cutting  pliers  after 
removal  of  its  periosteum. 

Von  Langenhech' 8  method  differs  slightly  from  the  above. 
He  begins  his  incision  at  the  anterior  border  of  the  aero- 
mion  just  outside  of  the  acromio-clavicular  junction,  and 
carries  it  directly  downward,  the  aiTU  being  so  held  as  to 
brincr  the  outer  condyle  of  the  humerus  in  front.  This 
sacrifices  the  inner  fibres  of  the  deltoid  by  severing  their 
nerves.  He  carries  the  incision  through  the  muscle  down 
to  the  ca])sule  and  bone,  then  raises  with  pronged  forceps 
the  sheath  of  the  tendon  of  the  biceps,  wdiich  presents  in  the 
line  of  the   incision,  and  opens  it  carefully  from  without 


148  EXCISION    OF    JOINTS    AND    BONES. 

inward.  As  soon  as  the  shining  tendon  is  seen  he  slits 
the  sheath  throughout  the  entire  length  of  the  incision, 
opening  the  capsule  quite  up  to  the  acromion,  and  exposing 
the  articular  end  of  the  humerus  with  the  tendon  lying 
upon  it. 

He  then  raises  the  periosteum  on  the  inner  side  until  the 
lesser  tuberosity  is  reached,  lavs  aside  the  elevator,  and 
peels  off  the  tendon  of  the  subscapular  with  knife  and 
pronged  forceps,  taking  the  greatest  pains  to  maintain  its 
relations  with  the  capsule  and  periosteum.  After  this  dis- 
section has  been  carried  as  far  as  possible  on  the  inner  side, 
he  lifts  the  tendon  of  the  biceps  from  its  sheath,  carries  it 
inward,  drops  it  into  the  joint,  and  denudes  the  bone  on 
the  outer  side  with  the  same  precautions,  using  the  knife 
instead  of  the  elevator  to  detach  the  capsule,  tendons,  and 
ligaments.     The  rest  of  the  operation  as  abov£. 

If  only  the  articular  head  of  the  bone  is  to  be  resected, 
near  the  upper  end  of  the  tuberosities,  there  is  no  perios- 
teum to  be  removed.  The  ligamentous  and  muscular  at- 
tachments  are  approached  from  within  the  joint,  and  the 
bone  divided  with  the  chain  or  keyhole  saw,  without  raising 
it  fi'om  its  place. 

By  a  Transverse  Incision.  (Xelaton,  Perrin.) — A  trans- 
verse incision  three  and  a  half  or  four  inches  long  is  made 
parallel  to  and  half  an  inch  below  the  edge  of  the  acromion, 
beginning  in  front  between  it  and  the  coracoid  process.  The 
fibres  of  the  deltoid  are  divided  close  to  the  acromion,  and 
by  their  retraction  expose  the  capsule  largely. 

The  capsule  is  divided  along  the  outer  edge  of  the  tendon 
of  the  biceps,  and  then  transversely  in  the  direction  of  the 
external  wound ;  the  bone  is  approached  and  denuded 
through  this  opening,  and  the  operation  completed  as  before. 

The  vessels  and  nerves  are  well  protected  by  this  method, 
but  it  is  very  difficult  of  execution. 

JExrision  of  the  Head  of  tJie  Scapula. — AYhen^the  disease 
is  confined  to  the  glenoid  cavity  and  the  neck  of  the  scapula, 
the  afiected  parts  can  be  removed  by  a  longitudinal  posterior 
incision  extending  fi-om  the  base  of  the  acromion  to  the  fold 
of  the  axilla. 


EXCISION    OF    THE    ELBOW-JOINT.  149 


EXCISION  OF  THE  HI.BOW-JolNT. 

Partial  excision  of  the  elbow-joint  for  disease,  even  wlien 
the  portions  left  behind  are  entirely  healthy,  is  more  dan- 
gerous and  gives  as  a  rule  less  satisfactory  results  than  com- 
plete excision.  The  humerus  should  be  sawn  through  at  or 
just  above  the  e}>icondyles,  the  ulna  at  the  luise  of  the 
coronoid  process,  and  the  radius  through  its  neck.  The 
extent  of  the  disease  may  make  it  necessary  to  surpass  these 
limits,  but  the  result  will  then  be  less  perfect,  and  in  any 
case  every  eftbrt  should  be  made  to  preserve  the  continuity 
between  the  periosteum  and  the  tendons  of  the  brachialis 
anticus  and  biceps  so  as  to  provide  for  future  flexion  of  the 
forearm.  An  exception  to  the  rule  of  total  excision  may  be 
found  in  the  preservation  under  some  circumstances  of  all 
the  olecranon  except  its  articular  surface;  the  joint  thus 
obtained  is  firmer,  and  active  extension  more  powerful. 

Reproduction  of  bone  takes  place  less  completely  at  the 
elbow-joint  than  at  any  other  of  the  major  articulations,  and 
consequently  the  greater  the  amount  removed  the  greater 
the  danger  of  the  formation  of  an  imperfect,  loose,  and  in- 
efficient joint,  even  when  the  subperiosteal  method  has  been 
thoroughly  carried  out.  Von  Langenbeck^  removed  four 
and  a  half  inches  of  the  humerus  and  two  inches  of  the 
ulna  subperiosteally  in  a  case  of  gunshot  injury,  and  says 
the  result  was  the  w^orst  he  ever  saw,  the  connection  be- 
tween the  arm  and  forearm  being  so  very  loose  that  the 
patient  was  obliged  to  use  a  supporting  brace,  by  the  aid  of 
which  he  was  able  nevertheless  to  make  excellent  use  of  his 
hand.  Ordinarily  anchylosis  is  to  be  preferred  to  a  very 
loose  joint. 

In  cases  of  gunshot  injury  Yon  Langenbeck  and  Oilier 
remove  as  little  as  possible,  making  a  partial  (semi-articular) 
excision  when  either  the  humerus  or  the  bones  of  the  fore- 
arm alone  are  injured.  The  English  authors  think  the 
danger  in  cases  of  excision  for  disease  is  rather  of  removing 
too  little  than  too  much,  and  reconmiend  that  the  humerus 
be  sawn  through  above  the  condyles. 

J  Loc.  cit.,  p.  443. 
13* 


150  EXCISIOX    OF    JOINTS    AND    BONES. 

As  the  joint  is  covered  anteriorly  "svith  soft  parts,  among 
which  lie  nearly  all  the  principal  arteries  and  nerves,  and 
is  almost  subcutaneous  posteriorly,  it  must  be  approached 
fi'om  the  latter  side,  and  the  incisions  must  be  made  with 
especial  reference  to  the  safety  of  the  ulnar  nerve,  where  it 
runs  between  the  olecranon  and  the  epitrochlear.  The  orig- 
inal method,  and  the  one  used  almost  exclusively  for  many 
years,  was  the  H-incision,  composed  of  two  longitudinal  in- 
cisions connected  midway  bv  a  transverse  one  crossincr  the 
tip  of  the  olecranon.  It  has  the  disadvantage  of  dividing 
the  ulnar  nei've  or  exposing  it  in  the  wound  during  the 
period  of  suppuration,  and.  having  been  superseded  by  less 
complicated  ones,  does  not  need  to  be  described. 

Although  excellent  joints  have  been  obtained  by  the  old 
operations  the  preference  should  be  given  to  the  modem 
subperiosteal  method,  not  only  on  account  of  the  greater 
certainty  of  the  reestablishment  of  a  useful  limb,  but  also 
because  the  danger  of  diffuse  inflammation  and  purulent 
infiltration  is  much  less  when  it  is  employed.  These  dangers 
are  greater  at  the  elbow  than  at  any  other  joint,  except  the 
hip,  and  secondary  amputation  is  more  frequently  required. 

The  other  methods  have  been  devised  with  the  view  of 
sparing  the  nerve,  presernng  the  attachment  of  the  triceps 
and  the  continuity  of  the  lateral  ligaments  with  the  perio.s- 
teum,  and  facilitating  the  operation.  Although  the  central 
longitudinal  incision  has  been  extensively  used  the  prefer- 
ence .seems  now  to  be  due  to  methods  of  approach  from  the 
radial  .side,  such  as  Olliers,  Nelaton's,  and  Hueter's. 

Central  LonfjitiLdinal  Incision.  Fig.  74.  A.  (Yon  Lan- 
genbeck.) — The  forearm  being  slightly  flexed,  a  longituchnal 
incision  3J  inches  long  is  made  a  little  to  the  inner  side  of 
the  median  line  of  the  triceps  and  ulna,  and  carried  down  to 
the  bone.  The  inner  edge  of  the  divided  periosteum  is 
raised  from  the  ulna,  the  corresponding  half  of  the  tendon 
of  the  triceps  detached  with  it,  and  the  dissection  continued 
toward  the  internal  condyle,  the  knife  beincr  kept  constantly 
against  the  bone,  and  the  flexion  of  the  arm  increased  as 
the  dis.section  advances.  As  the  epitrochlea  is  approached 
the  greatest  care  is  needed  to  preserve  the  connection  be- 
tween the  periosteum,  the  muscular  attachments,  and  the 


EXCISION    OF    THE    EL150  W-.J  OINT . 


151 


Fiu.  74. 


internal  lateral  ligament,  and  it  may  be  neeessary  to  \)\'() 
long  the  first  incision  upward  so  as  to  get  more  room. 

After  the  inner  half  of  the  joint  has 
thus  heen  laid  open  and  the  epitrochlea 
bared,  the  soft  parts  are  replaced  and  a 
similar  dissection  made  upon  the  outer 
side  Avith  the  same  precautions. 

The  humerus  is  then  dislocated  back- 
ward through  the  wound  and  sawn 
through  at,  or  as  near  as  possible  to,  the 
epicondyles,  according  tt)  the  lesion.  If 
the  condition  of  the  soft  parts  does  not 
allow  of  this  projection  of  the  humerus 
the  chain  or  keyhole  saw  must  be  used. 

The  ulna  is  then  cleaned  circularly  as 
far  as  necessary  and  sawn  through,  and 
the  head  of  the  radius  removed  with  the 
saw  or  cutting  pliers. 


Excision  of  the  elbow- 
joint.      A.   Von    Langen- 


OlUers  Method.'  (Fig.  74,  ^.)— The 
forearm  is  slightly  flexed,  and  an  incision 
is  commenced  two  inches  above  the  tip  beck.  b.  oiiier. 
of  the  olecranon  on  the  outer  side  of  the 
arm  at  the  interstice  between  the  triceps  and  supinator 
longus.  This  incision,  involving  the  skin  only,  is  carried 
downward  to  the  epicondyle,  thence  dowmvard  and  inward 
in  the  line  of  the  upper  border  of  the  anconseus  to  the  ole- 
cranon, and  thence,  the  point  of  the  knife  touching  the 
bone,  directly  downward  along  the  inner  side  of  the  poste- 
rior aspect  of  the  ulna  for  one  or  two  inches. 

The  fascia  is  then  divided  in  the  line  of  the  incision,  and 
the  interstice  between  the  triceps  on  one  side  and  the  supi- 
nator longus,  radial  extensor,  and  anconseus  on  the  other, 
followed  down  to  the  capsule  and  bone.  The  capsule  is 
opened,  and  the  humerus  denuded  on  its  anterior  and  poste- 
rior faces  as  far  inward  as  possible,  care  being  taken  to 
maintain  the  relations  of  the  muscular  and  ligamentary 
attachments. 

The  tendon  of  the  triceps  and  the  periosteum  of  the  ulna 


1  Traite  de  la  Regeneration  des  Os,  p.  340. 


152 


EXCISION    OF    JOINTS    AND    BONES, 


are  next  detached,  and  in  separating  the  former  it  is  hetter 
to  begin  inside  the  joint  at  the  free  edge  of  the  olecranon. 

The  denudation  of  the  external  condyle  and  tuberosity  of 
the  humerus  is  then  completed,  and  the  external  lateral 
ligament  entirely  detached,  the  forearm  flexed  on  its  inner 
side,  and  the  end  of  the  humerus  dislocated  outward  into  the 
wound,  thus  rendering  the  difficult  dissection  of  the  project- 
ing epitrochlea  easier.  When  this  latter  has  been  com- 
pleted, the  periosteum  of  the  humerus  is  raised  circularly 
to  the  proper  height,  and  the  bone  sawn  through.  The 
head  of  the  radius  is  then  removed,  the  denudation  of  the 

ulna    completed,   and   the  bone  sawn 
T'iG.  75.  through  perpendicularly  to  its  axis. 


Nelatons  Method.  (Fig.  75,  A.) 
— A  longitudinal  incision  is  begun  on 
the  outer  border  of  the  humerus  be- 
tween the  triceps  and  supinator  lon- 
gus,  IJ  inches  above  the  end  of  the 
olecranon,  and  carried  downwards  for 
a  distance  of  3  inches.  A  transverse 
incision  cutting  through  to  the  bone  is 


t 


\B 


Excision  of  the  elbow-joint. 
A   Nelaton.    B,  0.  Hueter. 


next  made,  from  the  lower  end  of  the 
first,  across  the  ulna  to  its  inner 
border. 

The  triangular  flap  thus  formed, 
including  the  periosteum  of  the  ulna, 
is  dissected  up,  the  external  lateral 
and  orbicular  ligaments  divided,  and 
the  head  of  the  radius  removed.  The 
tendon  of  the  triceps  is  detached  and 
the  denudation  of  the  ulna  completed. 
The  ulna  is  projected  through  the  incision  by  bending 
the  forearm  toward  its  inner  side,  and  is  sawn  off. 

The  humerus  is  then  easily  turned  out  through  the  in- 
cision, denuded  from  below  upward  with  tlie  usual  precau- 
tions, and  sawn  oft'  at  the  desired  height. 

Long  Radi<il  Incision  (Hueter).^  (Fig.  75,  B  and  C.) 
— A  preliminary  longitudinal  incision,  half  an  inch  long,  is 

1  Deutsche  Zeitschrift  fiir  Chirurgie,  2d  vol.,  p.  G8. 


EXCISION    OF    THE    EL  HO  W -.J  O  I  NT  .  153 

first  inado  directly  do-wii  upon  tlic  tip  of  tlic  opitroclile;i,  <)r 
rather  oii  its  anterior  side,  so  as  more  surely  to  a\'oid  tlie 
ulnar  nerve  wliieli  lies  close  behind  it,  and  the  niuscular 
attaehments  and  the  internal  lateral  ligament  are  separated 
hy  cutting  around  this  prominence. 

The  main  incision  is  then  made  by  entering  tlie  knife 
above  the  i)oint  of  the  external  epicondylc  and  carrying  it 
straight  down  over  it,  thus  opening  the  joint  aiid  e\'])osing 
the  head  of  the  radius  by  dividing  the  external  jjiteral  liga- 
ment longitudinally  and  the  orbicular  ligament  transversely. 
The  head  of  the  radius  is' then  removed  after  sawing  through 
its  neck. 

The  operator  then  passes  his  left  forefinger  through  the 
wound,  first  to  the  anterior  surface  of  the  humerus  to  make 
the  capsule  tense,  and  guide  the  detachment  of  it  and  the 
periosteum,  and  then  along  the  posterior  surface  under  the 
tendon  of  the  triceps  with  the  same  object. 

It  is  not  necessary  to  carry  this  dissection  very  far  to- 
ward the  inner  side,  because  by  dislocating  the  ulna  forci- 
bly inw^ard  the  end  of  the  humerus  can  be  made  to  pro- 
ject through  the  radial  incision,  and  then  its  denudation 
can  be  easily  and  safely  completed,  and  the  bone  sawn 
through.  -p 

The  end  of  the  olecranon  is  then 
In'ought  into  the  centre  of  the  incision, 
and  the  separation  of  the  triceps  begun 
at  the  upper  free  edge  of  the  process 
with  vigorous  short  cuts  into  the  sub- 
stance of  the  bone,  so  that  it  is,  as  it 
were,  peeled  out  of  its  tendinous  envel- 
ope. When  the  proper  point  is  reached 
the  bone  is  sawn  through. 

Osteoplastic    method.     (Fig.    70.)  — 
This  operation,  characterized  by  primary 
division  of  the  olecranon  and  its  reunion 
at  the  close  of  the  operation,  was  pro- 
posed by  Von   Bruns,  and  was  at  first        osteoplastic  nietho-i. 
deemed    applicable    to    old,   irreducible,    ■^- v- ^losotig-Moorhof. 
and  to  iresh  compound  dislocations.    Its 
use  has  been  extended  to  operations  for  foreign  bodies  in  the 
joint,  for  anchylosis,  and  finally  to  those  for  fungous  arthritis. 


154  EXCISION    OF    JOINTS    AND    BONES. 

The  procedure  recommended  by  Von  Mosetig-Moorhof 
begins  by  a  transverse  incision  running  from  the  lowest 
point  of  the  external  cond3'le  across  the  olecranon  to  its 
inner  side,  thence  upward  alongsidef  the  olecranon  to  a  point 
one  inch  above  its  tip.  The  ulnar  nerve  is  then  dissected 
out  and  drawn  aside,  and  the  olecranon  divided  with  saw 
and  chisel  in  the  line  of  the  first  part  of  the  incision.  The 
flap  is  then  drawn  aside,  the  humerus  cleared  and  sawn  off 
below  the  epicondyles,  the  head  of  the  radius  removed,  and 
the  olecranon  scraped  and  reunited  with  a  silver  suture. 

I  think  this  exposure  of  the  ulnar  nerve  is  unnecessary 
and  objectionable,  and  have  modified  the  operation  by  using 
the  lower  two-tliirds  of  Ollier's  incision  and  making  a  second 
transverse  one  from  the  lower  end  of  the  first  across  the  base 
of  the  olecranon,  and  sawino-  the  latter  throuirh  in  this  line, 
but  somewhat  obliquely  from  below  upward,  into  the  joint. 
The  joint  was  then  further  opened  through  the  lateral  in- 
cision, the  external  condyle  denuded,  and  the  flap,  including 
the  upper  part  of  the  olecranon,  turned  upward  and  inward. 
This  exposed  the  joint  freely,  and  the  humerus  was  then 
readily  denuded  and  sawn  off  through  the  epicondyles.  The 
radius  was  then  protruded  and  sawn  through  at  the  neck, 
the  olecranon  thoroughly  scraped,  removing  most  of  the 
coronoid  process,  and  the  capsule  dissected  out.  As  the 
scraping  of  the  olecranon  had  left  its  sigmoid  cavity  much 
too  large,  I  removed  a  slice  one  centimetre  thick  along  the 
line  of  its  original  section  to  shorten  it,  and  then  wired  the 
pieces  together.  The  result  was  very  good,  and  active  ex- 
tension more  powerful  than  in  any  other  case  I  have  seen. 

Bilateral  Incisions. — Yogt^  speaks  highly  of  a  method 
by  which  he  accomplishes  the  same  result  without  division  of 
the  olecranon.  His  incision  begins  above  the  external  con- 
dvle  and  is  carried  well  below  the  head  of  the  radius,  divid- 
ing  the  orbicular  ligament ;  then  he  removes  the  periosteum 
from  the  radius  and  divides  it  with  saAv  or  chisel  just  above 
its  tuberosity,  draws  aside  the  edges  of  the  W(nmd,  and 
explores  the  joint.  If  it  is  extensively  diseased  he  makes  a 
second  incision  on  the  inner  side  beginning  above  and  a 

'  Centralblatt  fiir  Chirurgie,  1882,  p.  555. 


EXCISION    OF    ANCHYLOSED    ELBOW.  155 

lillle  Ix'liiiKl  (lie  cjiitroclilea,  ninl  cxtcndiiiii;  ahoiit  tlircc 
inc'lios  downward,  tlicn  witli  a  cliiscl  caits  away  tlic  atladi- 
mcnts  ol"  the  cxtcMisor  and  Hcxor  muscles  fV<»ni  I  lie  condvlos, 
k'a\  inn;  ;i  slit'll  of  l)ono  uttaclicd  to  tlicni,  draAvs  aside  tlie  soft 
parts,  divides  tlie  capsulo,  i-aises  the  periostciini  from  tlie 
humerus,  and  saws  oif  the  end  of  the  latter.  1'lien,  if  neces- 
sary, he  scrapes  away  the  surface  of  the  (decranon. 

Partial  Excision. — Ollier's  and  Hueter's  methods  are 
especially  ap})licable  to  that  form  of  semiarticular  excision 
in  which  only  the  lowel'  end  of  the  humerus  is  resected. 
Nelaton's  or  Von  Langenbeck's,  or  the  lower  part  of  Ollier's, 
can  be  used  for  the  removal  of  the  ends  of  the  ulna  and 
radius. 

EXCISION  OF  ANCHYLOSED  ELBOW. 

When  there  is  anchylosis  of  the  joint.  Von  Langenbeck's 
incision  can  be  used,  and  the  ulna  divided  with  a  chain- 
saw  after  it  has  been  denuded.  The  detachment  of  the 
capsule  and  periosteum  is  then  proceeded  with  upward,  and 
the  lower  end  of  the  humerus,  with  the  attached  ends  of  the 
bones  of  the  forearm,  projected  through  the  wound  and 
sawn  ofF- 

Or  the  osteoplastic  or  either  of  the  two  following  methods 
may  be  employed. 

Excision  of  Anchylosed  ETbotv  (Oilier). — An  incision 
two  and  a  half  inches  long  is  first  made  on  the  outer  and 
posterior  side  of  the  limb  and  carried  through  to  the  bone, 
its  centre  being  on  a  level  with  the  tip  of  the  olecranon. 
A  second  incision  one  and  a  half  inches  long,  involving  the 
skin  only,  is  made  on  the  inner  side  of  the  ulnar  nerve  at 
the  level  of  the  internal  border  of  the  humerus.  The  nerve 
is  found  on  dividing  the  fascia,  is  drawn  aside  together  with 
the  posterior  lip  of  the  wound  with  a  blunt  hook,  and  is  then 
entirely  out  of  the  way  of  injury. 

The  lips  of  the  two  wounds  are  separated,  the  periosteum 
detached,  a  narrow  saw  passed  under  the  triceps,  and  the 
humerus  sawn  nearly  through  from  behind  forward,  leaving 
a  thin  shell  of  bone  in  front   which  is  then  broken.     The 


156  EXCISION    OF    JOINTS    AND    BONES. 

conditions  are  now  those  of  a  movable  joint,  and  more  or 
less  of  the  lower  frairment  or  of  each  frag-ment  is  removed, 
according  to  the  condition  of  the  bone.  The  triceps  should 
be  detached  before  the  olecranon  is  divided. 

Excision  of  AnchyJosed  Elbow  (P.  Heron  Watson^). — 
This  method  is  intended  only  for  the  removal  of  the  arti- 
cular end  of  the  humerus,  in  cases  of  more  or  less  complete 
anchylosis  following  injury.  The  advantages  claimed  for 
it  are  that  it  leaves  the  attachments  of  the  triceps  and 
brachialis  anticus  undisturbed,  and  limits  the  area  of  the 
operation  almost  exclusively  to  within  the  capsular  ligament, 
and  thereby  seems  to  secure  a  more  speedy  healing  of  the 
wound.  Watson  has  used  it  in  six  cases,  in  all  of  which 
the  results  were  satisfactory. 

1.  A  linear  incision  is  made  over  the  ulnar  nerve  at  the 
inner  side  of  the  olecranon.  2.  The  nerve  is  carefully 
turned  over  the  inner  condyle.  3.  A  probe-pointed  bis- 
toury is  introduced  into  the  elbow-joint  in  front  of  the  hu- 
merus and  then  behind  that  bone,  and  carried  upward  so 
as  to  divide  the  upper  capsular  attachments  in  front  and 
behind.  4.  A  pair  of  bone  forceps  are  next  employed  to 
cut  off  the  entire  inner  condyle  and  trochlea  of  the  humerus 
[from  above  downward],  and  then  introduced  in  the  oppo- 
site direction  [from  below  upward  and  outward]  so  as  to 
detach  the  external  condyle  and  capitulum  of  the  humerus 
from  the  shaft.  5.  The  angular  end  of  the  humerus  is 
turned  out  through  the  incision  and  sawn  off  square.  6. 
The  external  condyle  and  capitulum  are  removed  partly  by 
twisting,  partly  by  dissection,  without  any  division  of  the 
skin  on  the  outer  side  of  the  arm. 

If  there  is  dense  osseous  union  that  cannot  be  overcome 
by  flexion  and  extension  under  chloroform,  the  humerus 
must  be  divided  through  the  condyle  with  bone  pliers,  and 
the  operation  completed  as  above. 

EXCISION  OF  THE  WRIST. 

In  1863  Prof.  Lister  was  called  upon  to  treat  a  case  of 
compound  fracture  and  dislocation  of  the  wrist  in  a  youth 

1  Edinburgh  Med.  Journ.,  May,  1873,  p.  986. 


EXCISION    OF    TUK    WRIST.  157 

of*  sovc'iitcc'ii,  ill  wliicli  llic  ends  of  the  Ixdics  ot"  llic  loroiiriii 
projoctt'd  OIK'  and  a  lialf  iiiclics  tlir(ni<!;li  a  wound  on  tlic 
palmar  aspect,  lie  resected  the  ends  of"  llie  bones  an<l 
rei)laced  the  parts;  five  niontlis  afterward  tlie  injiii-ed  wrist 
w^as  as  useful  and  as  freel)'  movable  as  the  other,  altliou;i;h 
consideraldy  smaller.  Other  surgeons  had  had  a  similar 
experience  and  had  re})orted  it/  but  to  Prof.  Lister  belongs 
the  credit  of  detecting  the  principle  involved  and  of  estab- 
lishing upon  it  a  new  and  highly  succes.sful  method  of  ope- 
ration, one  wliicli  has  practically  superseded  all  others.  He 
has  not  formulated  the  ti*eatment  of  traumatic  cases,  but  in 
excision  for  chronic  disease  he  advises  the  removal  of  all 
the  carpal  bones,  except  possibly  the  pisiform  and  the  hook- 
like process  of  the  unciform,  and  of  the  articular  surfaces 
of  those  of  the  metacarpus  and  forearm  if  the  bones  them- 
selves are  not  moi'e  than  superficially  affected ;  if  on  exami- 
nation they  prove  to  be  more  deeply  involved,  he  uses  the 
cutting  pliers  and  gouge  freely.  In  one  instance  he  hol- 
lowed out  the  entire  shaft  of  the  third  metacarpal  bone, 
leaving  it  a  mere  shell,  and  the  case  did  well.  In  his 
earlier  operations  he  divided  the  radius  and  ulna  trans- 
versely about  an  inch  al)ove  the  joint,  but  as  these  bones 
are  usually  affected  but  slightly,  he  now  removes  only  a 
thin  slice  from  the  end  of  the  radius,  and  cuts  through 
the  ulna  obliquely,  so  as  to  take  away  all  the  part  that 
is  covered  with  cartilage  and  leave  the  styloid  process 
(Fig.  77). 

The  principles  involved  in  the  treatment  of  traumatic 
cases,  especially  after  gunshot  injury,  are  not  yet  well 
established.  Von  Langenbeck^  inclines  toward  primary 
excision  whenever  the  injury  is  severe,  and  thinks  it  may 
safely  be  partial  instead  of  complete.  The  exuberant  growth 
of  bone  which  characterizes  this  locality  occurs  during  con- 
servative treatment  as  Avell  as  after  excision,  and  its  inter- 
ference with  the  function  of  the  member  is  likely  to  be  even 
greater  in  the  former  than  in  the  latter  case. 

Posteriorly  and  laterally  the  wrist  is  covered  only  with 
skin  and  tendons,  with  no  arteries  or  nerves  of  importance 

^  Just:    De  resect.  epip]iy.s.  cum  decjip.    radii    exemplo.,  Leipzit^, 
1840.     Verbecck,  Bull,  de  I'Acad   dc  Med.  de  IJelgique,  vol.  iii. 
■■^  Langenbeck's  Arcliiv,  vol.  xvi. 

14 


158 


EXCISION    OF    JOINTS    AND    BONES. 


except  the  radial  artery,  Avliich  ayIikIs  around  the  outer  side 
to  pass  again  through  the  first  metacar|)al  space  to  the  pal- 
mar aspect  of  the  hand,  and  form  the  deep  palmar  arch 
just  below  the  bases  of  the  metacar})al  l)ones.  Between 
the  extensor  tendons  of  the  thumb  and  of  the  forefinger 
exists  a  triangular  interval,  shown  in  figure  78,  the  apex  of 
which  is  directed  upward  and  lies  near  the  middle  of  the 
dorsal  aspect  of  the  epiphysis  of  the  radius.  Within  this 
space  are  found  only  the  tendons  of  the  long  and  short  ex- 

FiG.  77. 


Excision  of  the  wrist,  Lister.  A.  Deep  puliiiar  arch  B.  Trapezium.  C  Articular 
surface  of  nlna.  The  dotted  hues  include  the  amount  removed  in  the  earlier  operation.^ ; 
the  unshaded  ixirtions  repre.sent  those  removed  when  the  disease  is  limited  to  the  carpus. 


tensores  carpi  radiates,  with  their  insertions  into  the  second 
and  third  metacarpals,  and  as  experience  has  shown  that 
these  tendons  can  be  detached  or  divided  without  prejudice 
to  the  subsequent  usefulness  of  the  hand,  the  articulation 
can  be  safely  approached  through  this  space. 

The  extensor  tendons  are  lodged  in  deep  grooves  upon 
the  surface  of  the  radius,  from  Avhich  it  is  very  difficult  to 
raise  them  without  opening  their  sheaths,  and  therefore  if  it 
is  necessary  to  take  more  than  a  thin  slice  from  the  bevelled 
end  of  the  bone,  it  should  be  done  with  a  gouge  and  as  a 


EXCISION    OF    THE    WRIST 


159 


lute   step   ill    the   operation.      In  tliis  way  it  is  possible  to 
leave  the  tendons  unhurt,  and  even  unseen. 

On  the  inner  side  the  tendon  of  the  extensor  earpi  ulnaris 
covers  the  ulna,  in  front  of  it  passes  the  flexor  carpi  ulnaris 
on  its  way  to  its  insertion  into  the  pisiform  hone  an<l  the 
base  of  the  fifth  metacarpal.  The  anterior  aspect  is  occu- 
pied by  the  numerous  and  important  flexor  tendons,  the 
median  and  ulnar  nerves,  and  several  arteries  or  arterial 
branches  of  considerable  size.  Toward  the  outer  side  the 
tendon  of  the  flexor  carpi  radialis  passes  through  a  groove 
on  the  surface  of  the  trapezium,  to  be  attached  beyond  the 
base  of  the  second  metacarpal.  An  ulnar  incision  should 
pass  between  the  flexor  and  extensor  carpi  ulnaris  at  the 
anterior  border  of  the  ulna. 

Fig.  78. 


Excision  of  the  wrirt,  Lister.     A.  The  radial  arterj-.  B.  Extens<jr  .sccuiuli  internoiiii 

fMfUicis.     L   Ext.  comui.  digitonim.     E.  Ext.  miu.  dig.  F.  E.xt.  i)riiu.  int.  jkiI.    G.  Ext. 

OSS.  met.  poll.     H.  I.  Ext.  carp    rad    long,  and  brev.  K.  Ext   carp   ula.     L,  L.  Line 
uf  radial  incision. 

BUateral  Incision^  (Lister').     Figs.  "8  and  79,  A,  B. — 
All  adhesions  are  first   broken  down  by  freely  moving  all 


*  Lancet,  1865,  p.  385,  slightly  abridged. 


160  EXCISION    OF    JOINTS    AND    BONES. 

the  articulations  of  the  liand.  Tlie  radial  incision  is  made 
in  the  situation  indicated  by  the  line  L  L  in  Fig.  78,  or 
Ficr.  79,  A.  It  commences  above  at  the  middle  of  the 
dorsal  aspect  of  the  radius  on  a  level  Avith  the  styloid  pro- 
cess. Thence  it  is  at  first  directed  toward  the  inner  side  of 
the  metacarpo-phalangeal  articulation  of  the  thumb,  run- 
ning parallel  to  the  tendon  of  the  extensor  secundi  inter- 
nodii :  on  reachins:  the  radial  border  of  the  second  meta- 
carpal  bone  it  is  carried  downward  longitudinally  for  half 
the  length  of  the  bone. 

The  soft  parts  on  the  radial  side  of  the  incision  are  next 
detached  from  the  bones  with  the  knife  guarded  by  the 
thumb-nail,  so  as  to  divide  the  tendon  of  the  extensor  carpi 
radialis  longior  at  its  insertion  into  the  base  of  the  second 
metacarpal,  and  raise  it  along  with  that  of  the  extensor 
brevier,  previously  cut  across,  and  the  extensor  secundi  in- 
ternodii,  while  the  radial  artery  is  thrust  somewhat  out- 
w^ard.  The  trapezium  is  then  separated  from  the  rest  of 
the  carpus  by  means  of  cutting  forceps  applied  in  a  line 
with  the  longitudinal  part  of  the  incision.  The  removal  of 
the  trapezium  is  reserved  till  the  rest  of  the  carpus  has 
been  taken  away.  The  soft  parts  on  the  ulnar  side  of  the 
incision  are  now  dissected  up  as  for  as  is  convenient,  the 
extensor  tendons  being  relaxed  by  bending  back  the  head. 

The  knife  is  next  entered  on  the  inner  side  of  the  arm, 
two  inches  above  the  end  of  the  ulna,  immediately  anterior 
to  the  bone,  and  is  carried  downward  l)etween  it  and  the 
flexor  carpi  ulnaris,  and  on  in  a  straight  line  as  far  as  to 
the  middle  of  the  fifth  metacarpal  bone  at  its  palmar  aspect 
(Fig.  79,  B).  The  dorsal  lip  of  the  incision  is  raised,  and 
the  tendon  of  the  extensor  carpi  ulnaris  cut  at  its  insertion 
into  the  fifth  metacarpal,  and  dissected  up  from  its  groove 
in  the  ulna,  care  beino;  taken  to  avoid  isolatinc^  it  from  the 
integuments,  and  thus  endangering  its  vitality.  The  ex- 
tensors of  the  finger  are  then  readily  separated  from  the 
carpus,  and  the  dorsal  and  internal  ligaments  divided,  but 
the  connections  <»f  the  tendons  witli  the  radius  are  purposely 
left  undisturbed. 

The  anterior  surface  of  the  ulna  is  tlien  cleared  by  cut- 
ting toward  the  bone,  so  as  to  avoid  the  artery  and  nerve ; 
the  articulation  of  the  pisiform  is  oj^ened,  if  that  has  not 


EXCISION    OF    THE    VVKIST.  UJl 

been  nlivady  done  in  iiiiikiiiir  the  incision,  and  tlie  flexor 
tvnditns  are  separated  from  the  earpus.  While  this  is  bein" 
done  the  knife  is  arrested  by  the  process  of  tlie  uneif(nin 
bone  which  is  clij)i)ed  tlirou^ih  at  its  base  with  j)liers.  The 
knife  must  not  be  carried  further  down  the  hand  than  the 
ba^es  of  the  metacarpal  bones,  so  as  not  to  injure  the  dee}) 
palmar  arch.  The  anterior  li<i;ament  of  tlie  wrist-joint  is 
divided,  after  which  the  junction  between  the  carpus  and 
metacarpus  is  severed  with  cutting  pliers,  and  the  carpus 
extracted  through  the  ulnar  incision  by  seizing  it  with  strong 
force})S  and  touching  with  the  knife  any  ligamentous  con- 
nections that  may  remain  undivided. 

'.riie  hand  being  now  forcibly  everted  the  articuhir  ends 
of  the  radius  and  ulna  will  protrude  at  the  ulnar  incision. 
If  they  appear  sound  or  only  superficially  affected,  the  arti- 
cular surfaces  only  are  removed.  The  ulna  is  divided  ob- 
liquely with  a  small  saw,  so  as  to  take  away  the  cartilage- 
covered  rounded  part  over  which  the  radius  sweeps,  while 
the  base  of  the  styloid  process  is  retained.  The  end  of  the 
radius  is  then  cleared  sufficiently  to  allow  a  thin  slice  to  be 
sawn  off  parallel  to  the  general  direction  of  the  inferior 
articular  surface,  and  the  articular  facet  on  the  ulnar  side 
of  the  bone  is  clipped  away  with  bone  forceps.  If,  on  the 
other  hand,  the  bones  prove  to  be  deeply  carious,  the  pliers 
or  gouge  must  be  used  with  the  greatest  freedom. 

The  metacarpal  bones  are  next  dealt  with  on  the  same 
principle.  If  sound  only  the  articular  surftices  are  clippe<l 
off. 

The  trapezium  is  next  seized  w^ith  forceps  and  dissected 
out,  so  as  to  avoid  cutting  the  tendon  of  the  flexor  carpi 
radialis  which  is  firmly  bound  into  the  groove  on  its  palmar 
aspect,  the  knife  being  also  kept  close  to  the  bone  elsewhere 
to  preserve  the  radial  artery.  The  articular  end  of  the 
first  metacarpal  is  then  removed.  Lastly,  the  articular 
surface  of  the  ])isiform  is  clipped  off,  the  rest  of  the  bone 
being  left  if  sound.  The  process  of  the  unciform  is  also 
left  if  sound.  The  radial  wound  may  be  closed  with  sutures, 
but  the  ulnar  one  must  be  kept  open  for  drainage,  and  the 
limb  must  be  bound  upon  a  splint  in  such  manner  that  while 
the  wrist  is  firmly  fixed  passive  motion  can  be  given  regu- 
larly to  the  finiiers. 

14* 


162 


EXCISION    OF    JOINTS    AND    BONES. 


Radial  Incision  (Oilier).  Fig.  79,  C. — An  incision 
involving  only  the  skin  is  begun  on  the  outer  side  of  the 
wrist,  an  inch  below  the  styloid  process  of  the  radius,  and 
carried  upward  along  the  outer  border  of  the  bone  for  a 
2:reater  or  less  distance,  according;  to  the  amount  to  be  re- 
moved.  A  cutaneous  branch  of  the  radial  nerve  is  exposed 
and  drawn  aside,  the  fascia  divided,  and  the  extensor  ten- 
dons of  the  thumb  recognized.  These  tendons  are  a  guide 
which  is  easily  found.     They  are  superficial,  and  contained 

Fig.  79. 


Exci.sion  of  the  wi'ist.     A.  Lister's  radial  incision.     B.  Lister's  ulnar  incision. 
G.  oilier.     D.  Von  Langenbeck. 


in  a  separate  groove.  On  opening  the  sheath  and  drawing 
them  aside,  the  insertion  of  the  supinator  longus  is  exposed, 
on  the  outer  side  of  which,  and  parallel  to  the  tendon,  the 
periosteum  of  the  radius  must  then  be  divided. 

Using  a  straight,  sharp  elevator,  the  surgeon  next  de- 
taches the  tendon  of  the  supinator,  preserving  its  relations 
with  the  periosteum,  and  then  denudes  the  lower  end  of  the 
radius  inward,  removing  periosteum  and  capsule.  Then, 
bending  the  hand  forcibly  toward  its  inner  side,  he  sepa- 
rates the  remaining  fibrous  attachments  and  dislocates  the 
lower  end  of  the  radius  outward.     The  ulna  can  be  pro- 


EXCISION    OF    THE    WRIST.  163 

ti-iided  throiiL^i  the  same  wound  and  dcnudcMl  fnmi  below 
u})ward,  but  it  is  better  to  make  a  loiigitudinal  incision  on 
the  inner  side  for  this  purpose. 

The  ends  of  the  radius  and  ulna  are  then  sawn  off,  and 
through  the  gap  thus  left  the  carpal  bones  are  successively 
removed  with  gouge  and  forceps. 

Borso-radinl  Twhion  (Von  Langenbeck).  Fig.  71',  D. 
— The  hand  is  bent  toward  the  inner  side,  and  an  incision 
is  begun  at  tlie  ulnar  border  of  the  second  metacarpal  bone 
near  its  middle  and  carried  upward  four  inches,  crossing 
the  ulnar  edge  of  the  tendon  of  the  extensor  carpi  radialis 
brevior,  where  it  is  inserted  into  the  l)ase  of  the  third  meta- 
carpal bone,  and  splitting  the  dorsal  ligament  of  the  wrist 
exactly  between  the  tendons  of  the  extensor  secundi  inter- 
nodii  and  extensor  of  the  forefinger.  This  incision  should 
be  carried  down  to  the  bone,  and  the  soft  parts  detached  on 
the  radial  side  with  an  elevator ;  the  tendons,  where  they 
lie  in  the  jirooves,  are  raised  bodilv  with  the  periosteum, 
and  their  sheaths  are  not  opened. 

The  hand  is  flexed  so  as  to  make  the  first  row  of  carpal 
bones  present  in  the  wound :  the  scaphoid  is  separated  from 
the  trapezium  and  taken  out,  and  followed  in  turn  by  the 
semilunar  and  cuneiform,  the  interosseous  ligaments  being 
cut  and  the  bones  pried  out  with  a  small  elevator.  The 
trapezium  and  pisiform  are  left  if  possible. 

To  take  out  the  second  row,  the  operator  steadies  the 
round  articular  end  of  the  os  magnum  with  the  fingers  of 
his  left  hand,  and,  while  an  assistant  abducts  the  thumb,  he 
divides  with  a  knife  the  connection  between  the  trapezium 
and  trapezoid,  passes  the  knife  into  the  carpo-metacarpal 
joint,  and  cuts  the  ligaments  on  the  dorsal  side  of  the  ends 
of  the  metacarpal  bones  while  an  aid  flexes  them.  In  this 
way  the  trapezoid,  magnum,  and  unciform  can  be  brought 
out  together. 

The  lateral  ligaments  are  then  carefully  separated  from 
the  radius  and  ulna,  the  bones  protruded  and  sawn  through. 


164  EXCISION    OF    JOINTS    AND    BONES. 


EXCISION    OF    THE    HIP-JOINT. 

In  this  joint,  as  in  the  shoulder,  the  disease  is  often  con- 
fined to  the  head  of  the  bone,  and  under  such  circumstances 
partial  excision  should  be  performed.  AYhen  the  acetabulum 
is  diseased  the  loose  pieces  must  be  picked  out,  and  the 
gouge  applied  to  the  roughened  surface.  The  line  of  sec- 
tion of  the  femur  should  pass  below  the  great  trochanter, 
however  limited  the  disease  may  be,  for  if  this  process  is 
left  it  is  liable  to  protrude  through  the  w^ound  and  obstruct 
the  escape  of  the  secretions.  If  the  disease  extends  be- 
yond this  point  additional  slices  must  be  removed,  or  the 
gouge  used  until  healthy  bone  is  reached. 

The  anatomical  disposition  of  the  parts  is  such  that  the 
joint  is  best  approached  from  the  outer  and  posterior  aspect, 
the  incision  passing  over  the  top  of  the  great  trochanter. 
Different  surgeons  have  inclined  the  upper  part  of  the  in- 
cision forward  and  backward  at  various  angles,  or  have 
dissected  up  a  triangular  flap,  its  apex  directed  sometimes 
upward,  sometimes  downward. 

Smjre's  Method.  (Fig.  80,  J..)— Enter  the  point  of  the 
knife  midway  between  the  anterior  superior  spine  of  the 
ilium  and  the  top  of  the  great  trochanter,  and  drive  it  down 
to  the  bone :  then,  keeping  it  firmly  in  contact  with  the 
bone,  draw  it  in  a  curved  line  to  the  top  of  the  trochanter, 
midway  between  its  centre  and  posterior  border,  thence  for- 
ward and  inward,  makinor  the  whole  length  of  the  incision 
from  four  to  eight  inches,  according  to  the  size  of  the  thigh. 
Make  sure  that  the  periosteum  is  divided  throughout. 

Then,  draAving  aside  the  soft  parts,  divide  the  periosteum 
transversely  just  opposite  to,  or  a  little  above,  the  lesser 
trochanter,  carrying  the  division  as  far  as  possible  around 
the  bone.  Beginning  at  the  angle  formed  by  the  two  inci- 
sions, raise  the  periosteum  on  each  side,  together  with  its 
membranous  attachment,  as  far  as  the  dio^ital  fossa.  Then, 
substituting  a  knife  for  the  periosteal  elevator,  divide  the 
insertions  of  the  muscles  at  this  point,  keeping  close  to  the 
bone,  and  afterward  separate  the  remaining  periosteum  as 
far  as  can  be  done  without  tearino;  it.     Then  adduct  the  leg 


EXCISION    OF    THE    HIP-JOINT. 


165 


sli»^litlv  and  raise  tlic  licad  of  tlie  femur  gently  out  of  tlio 
acetabulum ;  this  will  detach  the  last  of  the  periosteum,  and 
allow  the  finger  to  be  passed  around  the  b(Uie  as  a  guide  for 
the  saw,  which  sliouhl  be  applied  just  above  the  lesser  tro- 
chanter. 

If  the  bone  cannot  be   readily  dislocated  saw  it  through 
first,  and  then  remove  the  head  with  the  forceps  or  elevator. 

Fig.  80. 


Exciskiu  of  Uie  hip.     A.  Sayro.     B.  Oilier. 

If  the  acetabulum  is  perforated  the  edges  must  be  chipped 
off  very  carefully  down  to  the  point  at  Avhich  the  periosteum 
on  the  pelvic  side  is  still  adherent. 

Olh'c/s  Method.  (Fig.  80,  B.) — Oilier  makes  a  some- 
what similar  incision.  It  begins  four  fino;er-breadths  below 
the  crest  of  the  ilium,  and  the  same  distance  behind  the 
anterior  superior  spine,  runs  downward  to  the  most  promi- 
nent part  of  the  great  trochanter,  and  thence  directly  down 
the  shaft  of  the  femur.     Its  upi)er  part  should  involve  the 


166  EXCISION    OF    JOINTS    AND    BONES. 

skin  and  fascia  only.  The  posterior  lip,  including  the 
glut^eus  maximiis,  is  drawn  l)ack,  exposing  the  glut?eiis 
medius,  the  fibres  of  which  are  then  separated  without  cut- 
ting them.  This  permits  the  attachments  of  the  glutaeus 
medius  to  be  preserved,  and  the  glutaeus  minimus  can  be 
exposed  by  drawing  apart  the  edges  of  the  opening  made 
in  the  other,  and  then  divided  in  the  same  manner  or  drawn 
forward  with  a  blunt  hook. 

The  capsule  is  split  from  the  edge  of  the  cotyloid  cavity 
to  the  digital  fossa,  and  detached  together  with  the  ten- 
dinous insertions.  The  head  of  the  femur  is  dislocated 
backward,  the  ligamentum  teres  divided,  and  the  denuda- 
tion continued  downward  to  the  lesser  trochanter.  The 
bone  is  then  protruded  and  sawn  off  with  a  chain  or  com- 
mon saw. 

Anterior  Incision. — Roser  recommends,  in  order  to  pre- 
serve the  trochanter,  an  anterior  incision  in  the  line  of  the 
neck  of  the  femur,  beginning  just  outside  the  crural  nerve, 
and  dividincr  the  iliacus.  rectus,  sartorius,  and  tensor  vao:in?e 
femoris.  The  capsule  is  divided  in  the  same  line,  the  head 
turned  forward  into  the  wound  by  rotating  the  thigh  out- 
Avard,  and  sawn  off. 

Liicke  and  Schede  have  modified  this  by  makins:  the  in- 
•  •  .        .  .  ''  .  ^ 

cision  vertical  instead  of  transverse,  beo-innincr  outside  the 

crural  nerve  a  little  below  and  to  the  inner  side  of  the  ante- 
rior superior  spine  of  the  ilium,  and  running  directly  down- 
ward. The  inner  borders  of  the  sartorius  and  rectus  are 
exposed  and  drawn  outward,  and  then  the  outer  border  of 
the  psoas-iliacus  exposed  and  drawn  inward.  Then  the 
thigh  is  flexed,  abducted,  and  rotated  outward,  and  the  cap- 
sule divided. 


ANCHYLOSIS    OF   THE    HIP-JOIXT. 


When  the  anchylosis  is  not  associated  with  the  loss  of  a 
great  part  of  the  head  and  neck  of  the  femur,  that  is,  when 
it   follows   inflammation   of   the   joint   due  to   rheumatism, 

^  This  subject,  which  properly  belongs  under  osteotomy,  is  placed 
here  on  account  of  its  intimate  relations  with  excision  of  the  joint. 


ANCHYLOSIS    OF    THE    HIP-JOINT. 


167 


pyj^mia,  tiauinatism,  or  chronic  disease  that  lias  heeii  ar- 
rested at  an  early  staire,  Mr.  Adaniss  oj)erati«»n  of  siil»- 
eutaneous  division  of  the  neck  of  the  femur  may  be  appli- 
cable, but  usually  division  below  one  or  both  of  tlie  trochan- 
tei*s,  or  excision  of  the  head  and  neck,  is  to  be  preferred. 

Division  below  the  lesser  trochanter  is  only  undertaken 
to  remedy  a  faulty  position  of  the  limb,  for  there  can  be  no 
question  of  establishing  a  new  joint  below  the  insertion  of 
the  psoas  and  iliacus.     It  is  doubtful  also  if  a  permanently 


Fig.  81. 


Subcutaneous  divi  - 


neck  of  the  femur. 


movable  joint  can  be  obtained  by  division  at  a  liigher  point : 
it  certainly  cannot  unless  a  portion  of  the  bone  is  removed, 
and  probably  not  even  then,  for  the  tendency  of  the  cut 
ends  to  unite  after  a  time  is  very  great. 

Subcutaneous  Division  of  the  Xeck  of  th>  F' mur 
(Adams^). — The  only  special  instrimient  needed  is  a  saw 
somewhat  resembling  a  tenotomy  knife,  the  cutting  part 
beinof  one  and   a   half  inches  lonor  and  three-eio;hths  of  an 


^  A  new  operation  for  bony  anchylosis  of  the  hip-joint  with  mal- 
position of  the  limb,  by  subcutaneous  division  of  ilie  neck  of  the 
thigh  bone,  by  William  Adams.  London,  1871.  Reprinted  from 
the  British  Medical  Journal  for  December  24,  1870. 


168  EXCISIOX    OF    JOINTS    AXD    BOXES. 

inch  wide,  and  the  shank  about  two  and  a  half  inches  long. 
(Tig.  82.) 

A  tenotomy  knife  is  entered  a  little  above  the  top  of  the 
great  trochanter  and  pushed  straight  into  the  neck  of  the 
femur,  dividing  the  muscles  and  opening  the  capsule  freely. 
The  soft  parts  being  fixed  by  the  thumb  and  fingers  of 
the  left  hand,  the  knife  is  witlidrawn  and  the  saw  passed 
promptly  down  to  the  bone  through  the  track  made  by  it. 

Fig.  82. 


Adams's  saw  for  subcutaneous  division  of  the  neck  of  the  femur. 

The  bone  is  then  sawn  through  from  before  backward,  so 
that  the  line  of  section  shall  be  at  right  angles  to  the  long 
axis  of  the  neck,  care  being  taken  to  avoid  cutting  obliquely 
through  the  neck,  or  in  a  direction  parallel  with  the  shaft  of 
the  bone. 

Division  helow  tlie  Trochanter. — This  operation,  often 
includinir  the  removal  of  a  wedcre  of  bone  from  the  outer 
side,  has  been  much  more  frequently  empl'oyed  for  the  re- 
lief of  a  faulty  position,  especially  of  flexion  and  adduction. 
One  orreat  advantacje  is  that  in  it  the  bone  is  divided  below 
the  attachment  of  the  anterior  ligament  and  capsule,  the 
retraction  of  which  maintains  the  faulty  position.  The 
objection  to  it,  because  of  which  some  prefer  to  excise  the 
joint,  is  that  it  only  substitutes  one  fixed  position  for  an- 
other. 

Operation. — The  trochanter  is  exposed  by  a  longitudinal 
incision  on  its  outer,  posterior  aspect,  the  peritoneum  divided 
and  raised  in  front  and  behind,  and  a  wedge  of  bone  re- 
moved by  chiseling  while  the  limb  rests  on  a  sandbag,  or 
with  the  exsector  or  saw. 

Excision. — Posterior  incision  as  above  described,  with 
such  modifications  as  may  be  made  necessary  by  dislocation : 
division  of  the  neck  with  the  saw,  if  possible,  otherwise  with 
the  chisel ;  then  removal  of  the  head,  or  what  remains  of  it, 
by  chiseling. 


EXCISION    OF    THE    HIP-JOINT 


169 


The  upper  end  (if  the  bone  is  then  lodged  in  the  aeetabii- 
lum,  after  suht-utaneous  division  of  sueh  muscles  and  soft 
parts  as  interfere  and  removal  of  the  upper  part  of  the 
trochanter,  if  necessary.  Extension  by  weight  and  })ulley 
must  be  kept  up  for  a  long  time. 

Operation  for  Estahlishinnit  of  a  False  Joint  (Sayre). — 
A  longitudinal  incision  six  inches  in  length  is  made  over  the 
irreat  trochanter,  commencino:  iust  above  its  crest  and  as 
near  as  possible  to  its  centre,  and  carried  directly  down  to 
the  bone.  A  transverse.incision  is  then  made  through  the 
skin  and  fiiscia  only  at  the  centre  of  the  posterior  lip  of  the 
first.  The  anterior  surface  of  the  bone  is  next  cleaned  with 
an  elevator  until  the  trochanter  minor  can  be  felt  with  the 
finger,  the  posterior  surface  similarly  treated,  and  the  chain- 
saw  passed  just  above  this  process. 

Fig.  83. 


Linei!  of  section  in  Sayre's  operation  for  anchylosis  of  hip-joint. 

A  curveti  section  of  the  bone  is  made  by  sawing  fii*st  up- 
ward and  outward,  then  outward,  and  finally  outward  and 
downward.  The  saw  is  passed  a  second  time  around  the 
bone,  and  the  lower  fracrment  divided  transversely  one- 
eighth  of  an  inch  below  the  beginning  of  the  first  line  of 
seA2tion.  (Fig.  88.)  The  portion  of  bone  thus  removed  is 
about  three-fourths  of  an  inch  thick  at  its  thickest  part. 

Probably  two  parallel  sections  one-half  or  three-quartei*s 
of  an  inch  apart  would  answer  equally  well. 

15 


170 


EXCISION    OF    JOINTS    AND    BONES. 


EXCISION  OF  THE  KNEE-JOINT. 


This  should  always  be  complete  to  this  extent,  that  a  slice 
should  be  taken  from  each  bone,  but  it  is  not  always  neces- 
sary to  remove  the  entire  articular  surface  of  the  femur. 
In  children  the  amount  removed  should  be  as  small  as  is 
consistent  with  removal  of  all  that  is  diseased.  It  is  recom- 
mended by  Spence  and  some  others  that  the  patella  should 
be  retained  if  not  diseased,  but  experience  has  shown  this 
to  be  unwise,  for  it  does  not  add  materially  to  the  strengtli 
of  the  subsequent  union,  and  the  bone  itself  is  likely  to 
become  carious. 

As  anchylosis  should  always  be  aimed  at.  the  incision 
may  cross  the  front  of  the  joint  and  divide  the  ligamentum 
patella  or  the  patella.     Some  surgeons  provide  for  drainage 

by  making  a  dependent  opening  in 
Fig.  84.  the  popliteal  space,  but  this  seems  to 

be  unnecessary. 


li.-J- — '. 


Semilunar  Incision.  (Fig.  84,  A.) 
— The  knife  is  entered  on  one  side  of 
the  limb  at  the  posterior  part  of  the 
condyle,  and  carried  across  midway 
between  the  patella  and  the  tuberosity 
of  the  tibia  to  a  corresponding  point 
upon  the  other  side.  This  incision 
should  extend  down  to  the  bone 
throughout,  dividing  the  ligamentum 
patellae.  The  flap  is  reflected,  the 
crucial  ligaments  divided  close  to  their 
attachment  to  the  tibia,  the  lateral 
lic^aments  divided,  the  end  of  the 
femur  cleared  as  far  as  may  be  neces- 
sary, with  especial  care  for  the  safety 
of  the  popliteal  vessels,  protruded 
through  the  wound,  and  sawn  off"  at 
the  point  indicated  in  Figs.  8o  and  ^(S.  The  line  of  section 
must  be  parallel  to  the  line  of  the  articulation,  not  at  a  right 
angle  to  the  axis  of  the  shaft,  for  that  is  directed  inward 
and  downward.     If  necessary,  additional  slices  of  the  bone 


Exci&iuu  ol  tile  kuee-juint. 

A.  Semilunar  incision. 

B.  Oilier" s  incision. 


EXCISION    OF    THE    KNEE-JOIXT.  171 

arc  ronioved,  or  tlio  irouge  is  used.  All  tlio  articular  carti- 
lage slioiiM  l»c  removed. 

The  end  of  the  tibia  is  next  projected,  cleaned,  and  sawn 
off  about  half  an  inch  below  its  upper  surface. 

In  sawing  the  bones  it  is  best  not  to  make  a  complete 
section  with  the  saw,  but  to  stoj)  a  little  short  of  the  poste- 
rior surface  and  complete  the  separation  by  fracturing  what 
is  left. 

Finally,  the  patella  is  taken  out,  an<J  diseased  portions  of 
the  synovial  membrane  scraped  or  clipped  off. 

Transversa  Incision.^-'Ylw  incision  should  cross  the  pa- 
tella at  or  just  below  its  centre  and  extend  beyond  the  centre 
of  the  condyle  on  each  side ;  at  each  end  should  be  made  a 
lonoj-itudinal  incision  extendinix  two  inches  above,  and  one 
inch  below  the  transverse  one.  The  remainder  of  the  ope- 
ration is  the  same  as  the  preceding. 

OUu'rs  Suhprrwste'tJ  Method.  (Fig.  84.  ^.)— An  in- 
cision is  begun  two  inches  above  and  to  the  outer  side  of  the 
patella,  and  carried  d<»wn  to  the  upper  and  outer  angle  of 
that  bone,  thence  alouij:  its  outer  edfre  and  that  of  the  liixa- 
mentum  patelli^  to  and  beyond  the  tuberosity  of  the  tibia. 
If  the  subject  is  exceptionally  muscular,  or  the  internal  con- 
dyle very  prominent,  the  incision  should  be  begun  nearer 
the  median  line  (Fig.  84.  B').  The  knife  should  penetrate 
to  the  bone  throughout,  and  open  the  capsule  of  the  joint. 

The  periosteum  of  the  outer  condyle  of  the  femur  with 
the  attachments  of  tlie  external  lateral  ligaments  and  exter- 
nal crastrocnemius  is  next  detached,  and  then  the  anterior 
surface  of  the  femur  cleared.  The  crucial  lio-aments  are 
cut,  and  the  patella  carried  over  the  internal  condyle  with 
the  aid  of  blunt  h«^oks. 

The  leg  is  then  bent  backward  and  inward,  the  end  of  the 
femur  ])rotruded  through  the  wound,  cleared  posteriorly,  and 
sawn  off.  The  upper  end  of  the  tibia  is  then  cleared  from 
above  downward,  as  far  as  may  hQ  necessary,  and  a  slice 
taken  off. 

If  the  patella  is  diseased  he  removes  it,  leaving  the  peri- 
osteum that  covers  its  anterior  surface. 


172  EXCISIOX    OF    JOINTS    AND    BONES. 

Extirpation    of    the   Knee-joint.— This  term    has   been 
given  to  the  systematic  removal  of  the  synovial  membrane. 

Fig.  85.  Fig.  86. 


Sections  to  show  the  position  of  the  epiphyseal  cartilage  at  the  knee  and  the  points  at 
which  the  section  ought  to  be  made  in  excision. 

The  incision  may  be  the  transverse  or  the  semilunar  above 
described.     After  the  joint  has  been  opened,  the  patella,  or 


EXCISION    OF    THE    ANKLE-JOINT.  173 

its  upper  half,  is  dnnvii  dowmvard,  the  soft  parts  dissected 
from  in  front  of  it,  the  tendon  of  tlie  quadriceps  divided  ob- 
li([uely  upward  until  the  fil)rous  synovial  sac  is  reached,  and 
then  tlu^  latter  drawn  down  and  dissected  away  from  the 
adjoining  soft  parts  and  the  l)one.  The  lower  portion  is 
removed  in  like  manner,  together  with  the  semilunai-  carti- 
laixes,  and  then,  after  division  of  the  lateral  and  crucial  li<'-a- 
ments,  the  posterior  portion  of  the  sac.  This  latter  part  of 
the  operation  may  be  facilitated  by  first  sawing  off"  the  bone 
that  is  to  be  removed.  Volkmann^  strongly  advises  that 
the  articular  surfiices  should  be  spared  unless  actually  dis- 
eased, and  that  the  interference  Avith  the  bone  should  be 
restricted  to  o;ou<2;ino;  out  tuberculous  foci. 

o       o      o 


EXCISION  OF  THE  ANKLE-JOINT. 

The  results  of  excision  of  the  ankle-joint  have  been,  on 
the  whole,  so  unfjivorable  that  the  English  and  German 
surgeons  are  inclined  to  abandon  it  entirely.  When  the 
operation  has  been  undertaken  on  account  of  caries,  the  dis- 
ease has  usually  returned  in  the  tarsal  bones,  and  rendered 
secondary  amputation  necessary.  When,  on  the  other  hand, 
it  has  been  performed  on  account  of  injury,  the  mortality 
has  been  great,  secondary  amputation  has  been  frequently 
required,  and  the  position  of  the  foot  in  the  cases  that  re- 
covered has  usually  been  faulty. 

The  results  of  conservative  expectant  treatment  have  been 
no  better,  and,  in  part,  for  the  same  reasons.  In  corre- 
spondence, as  has  been  pointed  out,  with  the  late  consolida- 
tion of  the  epiphysis,  inflammation  of  this  extremity  is  likely 
to  be  severe,  and  its  destructive  results  extensive ;  the  re- 
production of  bone  is  also  very  abundant  and  leads  almost 
necessarily  to  anch^dosis,  so  that,  unless  great  attention  is 
given  to  maintaining  the  foot  in  a  proper  position  during  the 
whole  period  of  treatment,  it  will  unite  at  a  faulty  angle 
with  inversion  or  eversion  of  the  sole,  and  inability  to  sup- 
port the  weight  of  the  body. 

As  anchylosis  is  to  be  expected,  the  rule  in  excision  is  to 

^  Centralblatt  liir  Chirurgie,  1885,  p.  139. 
lo* 


174 


EXCISION    OF    JOINTS    AND    BONES 


Fig.  8"; 


remove  the  smallest  possible  amount  of  bone,  and  to  make 
partial  instead  of  complete  excision  when  the  disease  does 
not  extend  to  the  whole  joint.  The  retention  of  one  or  the 
other  malleolus  is  a  great  help  in  preventing  shortening,  and 
in  the  use  of  a  plaster  splint.     The  interosseous  membrane 

between  the  tibia  and  fibula  must 
be  preserved  carefully.  It  not  only 
has  a  great  tendency  to  ossify,  but 
also  seems  to  favor  the  reproduction 
of  bone. 

Operation  (total  excision). — An 
incision  involving  only  the  skin  is 
begun  two  inches  above  the  exter- 
nal  malleolus  and  a  little  behind  the 
middle  of  the  fibula,  carried  directly 
down  to  the  end  of  the  bone,  and 
thence  forward  and  slightly  upward 
toward  the  instep  for  an  inch  (Fig. 
87).  The  periosteum  covering  the 
fibula  is  divided  throughout  and 
dissected  up  from  the  bone  with  the 
attachment  of  the  lateral  ligaments, 
especial  care  being  taken  not  to 
open  the  sheath  of  the  peroneal 
muscles  at  the  posterior  border  of 
the  malleolus,  and  to  remove  all  the 
,  thick  periosteum  and  the  interos- 
seous membrane  on  the  inner  side.  If  necessary,  a  trans- 
verse liberating  incision  may  be  made  through  the  periosteum 
at  the  upper  end  of  the  cut.  The  bone  is  then  divided  with 
a  keyhole  or  chain  saw,  the  upper  end  of  the  lower  fragment 
drawn  out  of  the  wound  to  expose  and  facilitate  the  separa- 
tion of  the  remaining  attachments,  and  the  piece  removed. 

The  soft  parts  are  then  held  out  of  the  way  with  retrac- 
tors, and  the  upper  articular  surface  of  the  astragalus  sawn 
off  with  the  keyhole  saw,  but  not  removed. 

The  foot  is  next  turned  upon  its  outer  side,  and  a  longi- 
tudinal incision  two  oi-  three  inches  long  made  along  the 
side  of  the  tibia,  ending  half  an  inch  below  the  tip  of  the 
malleolus,  where  it  is  then  crossed  by  a  short  horizontal 
one  involving  the  skin  onlv.     The  periosteum  of  the  tibia 


Excision  of  ankle. 


ANKLE:    VOGT's    METHOD.  175 

is  (livided  in  the  line  of  the  incision  und  transversely  at  its 
upper  end,  and  dissected  off,  the  bone  sawn  througli,  and 
the  piece  removed.  Langenbeck  makes  the  line  of  section 
obli(|ue  d()^vn^Yard  and  outward,  l)ecause  it  is  easier  to  do  so, 
but  most  surgeons  prefer  to  have  it  transverse.  The  u})per 
])art  of  the  astragalus,  which  has  been  previously  sawn  off, 
is  then  removed  through  the  same  incision. 

The  gouge  is  used  to  scrape  away  any  diseased  parts 
found  on  the  cut  surface  of  the  astragalus,  or  the  bone  may 
be  seized  wdth  strong  forceps  and  dissected  out  entirely. 

If  the  injury  has  affected  the  astragalus  only  (as  in  some 
gunshot  wounds),  its  splinters  are  best  removed  through  a 
longitudinal  incision  upon  the  dorsum  of  the  foot  between 
the  extensor  tendons  of  the  first  and  second  toes. 

Yogi's  3Iethod,  by  Rernoval  of  the  Astragalus. — A  se- 
rious objection  to  the  use  of  the  preceding  operation  in  cases 
of  tul)erculous  disease  lies  in  its  insufiicient  exposure  of  the 
interior  of  the  joint  to  view  and  it  has  been  proi)Osed  by 
Hueter  to  return  to  the  old  method  of  an  anterior  transverse 
incision  with  division  of  all  the  extensor  tendons,  and  by 
Busch  to  open  the  joint  by  cutting  across  the  sole  and  saw- 
ing through  the  calcaneum.  Vogt,^  however,  has  recently 
proposed  and  employed  another  method  which  avoids  this 
extensive  division  of  the  soft  parts  and  which  enables  the 
surgeon  to  explore  the  joints  thoroughly  and,  if  necessary, 
to  excise  the  synovial  membrane.  It  consists  in  primary 
methodical  extirpation  of  the  astragalus  w  ithout  resection  of 
the  malleolus. 

Operation. — A  longitudinal  incision  on  the  outer  side  of 
the  extensor  tendons,  three  or  four  inches  long,  beginning 
above  between  the  tibia  and  fibula,  and  ending  below  at  the 
line  of  the  calcaneo-cuboid  joint ;  after  division  of  the  fascia 
the  tendons  are  raised  in  their  sheaths,  carefully  separated 
from  the  underlying  parts,  and  strongly  retracted  to  the 
inner  side.  The  extensor  brevis  is  then  cut,  the  outer  side 
of  the  incision  retracted,  the  capsule  split  longitudinally  to 
its  full  extent  and  separated  on  both   sides  from  the  bone 

»  Centrulblatt  fiir  Cliirurgie,  1883,  p.  289. 


176  EXCISION    OF    JOINTS    AND    BONES. 

with  knife  and  elevator,  the  head  and  neck  of  tlie  astragalus 
cleared,  and  the  astragalo-scaphoid  ligament  divided. 

A  second  incision  is  made  from  a  point  somewhat  below 
the  centre  of  the  first  backward  below  the  external  malleolus, 
dividing  everything  down  to  the  astragalus,  but  sparing  the 
peroneal  tendons.  The  foot  is  then  supinated,  the  anterior 
ligaments  cut  away  from  the  external  malleolus,  and  the 
strong  interosseous  ligament  divided  by  thrusting  a  small 
strong  knife  into  the  groove  between  the  astragalus  and  cal- 
caneum.  The  head  of  the  astragalus  is  then  drawn  forcibly 
outward  with  a  stout  hook,  while  the  foot  is  supinated,  the 
deep  portion  of  the  internal  lateral  ligament  cut  by  passing 
a  knife  between  the  malleolus  and  the  astragalus,  the  latter 
drawn  forward  into  the  incision,  and  its  posterior  attach- 
ments cut. 

The  remainder  of  the  operation  will  vary  with  the  extent 
and  character  of  the  disease.  All  the  adjoining  bones  are 
freely  exposed  to  inspection,  and  can  be  scraped,  gouged 
out,  or  sawn  off. 

I  have  found  the  execution  of  this  operation  easy,  even 
when  the  capsule  was  much  thickened  by  disease,  and  its 
exposure  of  the  interior  of  the  joint  is  very  satisfactory. 


OSTEOPLASTIC  EXCISION  OF  THE  FOOT  (hEEL  AND  ANKLE) 

(Mikulicz). 

This  ingenious  operation,  the  results  of  which  have  proved 
very  satisfactory,  was  introduced  by  Mikulicz  in  1881.'  It 
is  specially  applicable  to  cases  in  which  the  integument 
about  the  heel  has  been  extensively  destroyed. 

Operation.  (Fig.  88.) — Abdominal  decubitus.  An  in- 
cision beginning  a  little  in  front  of  the  tubercle  of  the 
scaphoid  is  carried  directly  across  the  sole  of  the  foot  to  a 
point  just  behind  the  base  of  the  fifth  metatarsal  bone. 
From  each  end  of  this  one  another  incision  is  carried  back- 
ward nnd  upward  to  the  base  of  the  corresponding  malleolus, 
and  the  upper  ends  of  the  last  two  incisions  are  then  united 
by  a  fourth  which  passes   horizontally  across  and  divides 

1  Archiv  fi'ir  Klinisclie  Chirurgie,  vol.  2<j,  p.  191. 


OSTEOPLASTIC    EXCISION    OF    ANKLE. 


177 


the  tendo  Acliillis.     In   all  the  incisions  the  knife  is  made 
to  touch  tlie  hone  thi-ou<^hout. 

The  lateral  ligaments  of  the  ankle  are  next  divided,  the 
joint  opened  from  behind,  and  the  calcaneum  and  astragalus 


Fig.  88. 


Osteoplastic  excision  of  the  foot.     (Milvulicz.) 

carefully  dissected  from  the  tissues  in  front  of  the  incisions 
and  removed  by  disarticulating  at  the  mcdio-tarsal  joint. 

Finally,  the"^  malleoli  and  louver  articular  surface  of  the 
tibia  and'^the  posterior  portion  of  the  cuboid  and  scaphoid  are 
sawn  off  as  sliOAvn  by  the  dotted  lines  in  the  figure,  the  cut 
beintTf  made  from  behind  forAvard. 


178  EXCISION    OF    JOINTS    AND    BONES. 

The  cut  surfaces  of  bone  are  then  brought  into  apposition, 
and  fastened  together  with  nails  or  sutures,  and  the  wound 
closed.     Fig.  88,  B.  represents  the  result. 

EXCISION  OF  THE  BONES  AND  SMALLER 
ARTICULATIONS. 

EXCISION  OF  THE  SUPERIOR  MAXILLA. 

This  operation  may  be  required  on  account  of  malignant 
tumors  of  the  bone  or  antrum,  or  of  suppurative  osteitis  and 
necrosis,  or  to  give  access  to  the  base  of  implantation  of  a 
naso-pharyngeal  polyp.  In  the  first  case  the  periosteum 
should  not  be  retained;  in  the  second  its  separation  from 
the  bone  is  in  great  part  accomplished  by  the  inflammatory 
process ;  in  the  third  it  should  be  carefully  retained  so  as  to 
diminish  the  subsequent  deformity. 

In  total  excision  the  bony  connections  that  require  to  be 
divided  are :  (1)  The  one  with  the  malar  bone  below  the 
outer  angle  of  the  orbit.  (2)  That  with  the  opposite  bone 
along  the  centre  of  the  hard  palate.  (3)  Those  formed  by 
the  nasal  process  near  the  inner  angle  of  the  orbit;  and  (4) 
that  with  the  palate  bone  and  pterygoid  process  of  the 
sphenoid.  The  first  may  be  divided  by  nicking  the  anterior 
surface  of  the  bone  with  a  saw,  and  completing  the  division 
with  cutting  forceps,  or  Avith  chisel  and  mallet,  or  by  pass- 
ing a  chain-saw  around  it,  through  the  spheno-maxillary 
fissure  .in  the  orbit  and  zygomatic  fossa.  The  second  is 
divided,  after  having  drawn  one  or  both  incisor  teeth,  by 
means  of  a  saw  passed  into  the  nostril,  or  with  cutting  for- 
ceps with  long  narrow  blades,  or  a  chisel.  The  third  is 
easily  divided  Avith  forceps  or  a  chisel,  and  the  fourth  by 
tAvisting  the  bone  dowuAvard  after  all  the  other  connections 
have  been  severed. 

The  periosteum,  covering  the  floor  of  the  orbit,  is  thick 
and  easily  detached ;  that  on  the  hard  palate  is  thick  and 
difficult  of  removal,  on  account  of  the  irregularities  of  the 
surface.  There  is  but  little  danger  of  injury  to  the  internal 
maxillary  artery,  and  it  is  seldom  necessary  to  apply  more 
than  one  or  two  ligatures  to  its  divided  branches.  Oozing 
is  arrested  by  packing  Avith  antiseptic  gauze. 


EXCISION    OF    THE    SUPEKIOR    MAXILLA.      179 

Til  pai'ti;il  excision  tlio  orl)ital  ]»liit('  is  left,  tlic  line  of 
division  oi  the  hone  passin*.^  lhi"ou;j!;li  the  antcrioi-  wall  of  tlic 
antrum  from  the  nostril  to  the  loNver  corner  of  the  union 
^vith  the  malar  hone.  The  icniainini:  attachments  are  then 
broken  as  before.  There  are  also  other  varieties  of  partial 
excision  for  the  removal  of  naso-pharyngeal  l)olypi ;  removal 
of  the  nasal  process  with  the  nasal  bone ;  removal  of  part  of 
the  hard  palate  (Nelaton) :  and  temporal y  removal  of  dif- 
ferent portions,  })reserving  the  connection  with  the  soft 
parts,  and  replacing  them  after  the  polyp  has  been  removed. 

The  incisions  that  have  been  proposed  may  be  classed  as 
(1)  external  and  (2)  nredian  ;  the  former  extending  from 
the  angle  of  the  mouth  upward  and  outward  to  the  malar 
bone ;  the  latter  passing  from  or  near  the  middle  of  the  lip 
up  toward  the  inner  angle  of  the  eye.  The  former  are  open 
to  the  objections  that  they  divide  the  branches  of  the  facial 
nerve,  endanger  Steno's  duct,  and  leave  a  conspicuous  scar. 
The  preference  is  now  generally  accorded  to  the  median  in- 
cisions. These  follow  the  outline  of  the  side  of  the  nose 
more  or  less  closely,  and  some  of  them  are  supplemented  by 
a  transverse  incision,  passing  a  quarter  of  an  inch  below  the 
lower  margin  of  the  orbit.  For  partial  excision  Guerin  re- 
commends an  incision  passing  from  the  side  of  the  wing  of 
the  nose  along  the  naso-labial  fold  to  the  angle  of  the  mouth 
(Figs.  89  and  90). 

In  order  to  avoid  the  swallowing  of  blood,  it  is  well  not 
to  carry  the  incision  through  the  lip  or  divide  the  gingivo- 
labial  fold  until  after  the  anterior  face  of  the  bone  has  been 
denuded  as  far  as  possible. 

It  is  possible  to  remove  the  superior  maxilla  through  the 
mouth  without  making  any  cutaneous  incisions,  but  it  is  a 
very  difficult  and  painful  operation,  and  the  hemorrhage  is 
most  embarrassinoj.     Larorhi  has  removed  both  bones  throuofh 

0_  CD  _  O 

the  mouth,  upon  the  cadaver,  and  says  it  is  easier  to  remove 
l>oth  together  than  one  alone  in  this  way. 

In  simultaneous  excision  of  both  superior  maxilli^,  the 
same  incisions  mav  be  made  on  both  sides,  as  for  the  re- 
moval  of  only  one,  or  Dieffenbach"s  median  incision  may  be 
made  alons  the  ridire  of  the  nose  and  the  middle  of  the 
upper  li}) 


I). 


180 


EXCISION    OF    JOINTS    AND    BONES. 


Operation  by  one  of  the  Median  Incisions.  (Fig.  89.) 
— The  incision  is  made  in  the  direction  selected,  the  knife 
penetrating  to  the  bone  throughout  except  at  the  lip.  The 
cartilage  of  the  nose  is  separated  from  the  bone  and  reflected 
inward  with  the  small  internal  flap,  the  edge  of  the  orbit 
cleared,  and  the  external  flap  dissected  outward  as  far  as  to 
the  malar  bone  above  and  the  tuberosity  of  the  maxilla  below 
if  possible,  the  infraorbital  nerve  being  divided  at  its  point 
of  emergence  from  the  foramen. 

The  periosteum  of  the  floor  of  the  orbit  is  then  detached 
with  the  handle  of  the  knife,  as  far  as  the  spheno-maxillary 
fissure,  the  malar  process  or  bone  cut  through  with  the  saw 
or  forceps,  and  the  thni  plate  of  bone  forming  the  floor  of 

Fia.  89. 


Excision  of  superior  maxilla.     A.  External  incision.     B.  Xelaton's  incision. 
C.  Boeckel's  incision. 


the  orbit  divided  with  the  knife  obliquely  inward  and  forward 
fi'om  the  anterior  end  of  the  spheno-maxillary  fissure.  The 
superior  maxillary  nerve,  which  can  be  readily  distinguished 
through  the  bone,  should  also  be  divided  as  far  back  as  pos- 
sible.    Finally,  the  nasal  process  is  divided. 

The  incision  is  then  carried  through  the  lip,  and  the  de- 
tachment of  the  external  soft  parts  completed. 

The  mucous  mem])rane  of  the  roof  of  the  mouth  is  divided 
transversely  on  a  line  with  the  last  molar  tooth,  and  longi- 
tudinally in  the  median  line.  An  incisor  tooth  is  then 
drawn,  and  the  hard  ])alate  divided  with  saw  or  forceps 
close  to  the  septum. 


EXCISION    OF    THE    SUPERIOR     MAXILLA 


181 


If  the  mucous  membrane  (»f  the  roof  of  the  mouth  is  not 
diseased  it  may  be  retained.  Instead  of  the  incisions  tlimutrh 
it  just  mentioned,  one  is  made  along  tlie  inner  border  of  the 
alveolar  process,  its  edge  raised,  and  the  membrane  de- 
tached inward  and  backward  to  the  median  line.  After  the 
removal  of  the  hnne  it  unites  with  the  cheek,  closes  in  the 
mouth  as  before,  and  may  become  strengthened  bv  a  deposit 
of  bone. 

Finally,  the  bone  is  grasped  with  strong  forceps,  twisted 
downward  to  break  its  posterior  connections,  and  removed, 
generally  bringing  with  it  part  of  the  palate  bone,  the 
hamular  process  of  the  pterygoid  and  some  attached  mus- 
cular fibres. 

Subperiosteal  Excision  (Oilier). — This  method  can  be 
employed  with  any  of  the  median  incisions  above  mentioned, 
but  Oilier  prefers  an  external  one  (Fig.  90,  B). 

Fig.  90. 


Excision  of  superior  maxilla,     ii    Gaerio's  incbion.     B.  OUier's  inci^on. 
C.  Dieffenbach'*  incision  fi>r  removal  of  both  bones. 


1.  Cuttntt'ous  In'ision. — An  incision  is  made  from  the 
middle  of  the  malar  bone  to  a  point  on  the  upper  lip  one- 
third  of  an  inch  from  the  angle  of  the  mouth.  If  neces.sar3% 
a  second  incision  must  be  made  at  the  middle  of  the  lip  and 
carried  upward  around  the  nostril. 

16 


182  EXCISION    OF    JOINTS    AND    BONES. 

2.  Incision  of  3Iucous  Membrane. — The  incision  is  be- 
gun on  the  outer  surface  at  the  interval  between  the  second 
incisor  and  the  canine  tooth  (he  does  not  remove  the  inter- 
maxiUary  bone,  that  whicli  supports  the  incisor  teeth)  close 
to  the  ed«:e  of  the  o-um,  carried  back  around  the  last  molar, 
then  forward  on  the  inside  to  a  point  corresponding  to  that 
at  which  it  was  begun,  and  thence  obliquely  backward  to 
the  median  line.  A  short  incision  through  the  periosteum 
is  next  made  from  the  anterior  external  extremity  of  the 
former  upward  and  inward  to  a  point  a  quarter  of  an  inch 
external  to  the  anterior  nasal  spine. 

3.  Separation  of  the  Periosteum. — The  periosteum  of  the 
anterior  surface  is  then  detached  with  an  elevator,  care  being 
taken,  however,  to  divide  the  infraorbital  nerve  with  a  knife 
at  its  point  of  emergence,  and  the  denudation  is  carried 
along  the  floor  of  the  orbit.  Unless  it  is  necessary  to  re- 
move the  nasal  process  of  the  maxilla,  the  lachrymal  sac  and 
duct  can  be  left  uninjured  and  adherent  to  the  periosteum. 

The  periosteum  of  the  roof  of  the  mouth  is  then  separated 
from  without  inward  as  far  as  the  median  line. 

4.  Section  of  the  Bone. — The  nasal  and  malar  processes 
are  divided  with  forceps,  chisel,  or  chain-saw  as  before  de- 
scribed, the  canine  tooth  drawn,  the  edge  of  the  chisel  in- 
serted in  the  gap  left  by  it,  and  pressed  gently  backward 
and  inward  to  the  median  line,  thence  directly  backward 
along  the  suture. 

The  bone  is  then  twisted  out,  the  palatal  sutured  to  the 
external  periosteum,  and  the  wound  closed. 

SIMULTAXEOUS    EXCISION    OF    BOTH    SUPERIOR    MAXILL.E. 

An  incision  may  be  made  from  each  angle  of  the  mouth 
to  the  malar  bone  and  the  broad  flap  reflected  toward  the 
forehead,  or  Diefi"enbach's  incision  made  along  the  ridge  of 
the  nose  (Fig.  90,  C).  with  or  without  a  transverse  one  pass- 
ing across  it  and  below  the  margin  of  each  orbit. 

The  bones  are  removed  together,  not  separately.  The 
malar  processes  or  bones  are  divided  in  the  usual  manner, 
the  nasal  processes  divided  with  a  chain  saw  passed  from 
one  orbit  to  the  other  through  the  lachrymal  bones,  and  the 
vomer  separated  with  cutting  forceps.     The  periosteum  of 


EXCISION    OK    SUPEKIOH    MAXILLA.  183 

tlic  hard  palate  is  se})arat('(l  IVoin  the  gums  hy  a  seiiiicircii- 
hir  incision  and  dissected  back,  the  ])ostei-i(H-  connections 
broken  and  tlie  bone  removed  by  twisting  it  downward  ami 
forward. 


PARTIAL    AXJ)    TEMPORARY    EXCISION    OF    TlIK    SPPKRIOR 

MAXILLA    TO    FACILITATE    THE    P»F.M()V\I.    OF 

NASO-PIIARYX(}EAL    POIA'Pr<. 

Resection  of  Posterior  Portion  of  Hard  Palate  (Nela- 
ton). — Tlie  soft  palate  is  first  divided  fi'om  before  backward 
along  the  median  line,,  and  the  incision  prolonged  forward 
through  the  periosteum  of  the  hard  palate  as  far  as  may  be 
judged  necessary.  A  transverse  incision  is  next  made  on 
one  side  from  the  anterior  extremity  of  the  first  toward  the 
teeth,  and  the  flap,  including  half  the  soft  palate,  dissected 
off  the  bone  from  the  median  line  outward.  The  mucous 
membrane  on  the  floor  of  the  corresponding  nostril  is  then 
divided  close  to  the  septum,  the  bone  perforated  at  the  an- 
terior corners  of  the  denuded  surface,  and  the  separation  of 
the  quadrilateral  piece  accomplished  with  cutting  forceps. 

After  removal  of  the  polyp  the  soft  parts  are  replaced  and 
stitched  together.     The  bone  is  sometimes  reproduced. 

Resection  of  the  Upper  Portion^  leaving  the  Hard  Palate 
and  Alveolar  Process  (Von  Langenbeck). — The  following 
is  somewdiat  abridged  from  the  description  in  the  Deutsche 
Klinik^  1861,  page  288: 

An  incision  convex  downward,  from  the  ala  of  the  nose 
to  the  malar  bone,  and  along  the  zygoma  backward.  A 
second  incision  from  the  nasal  process  of  the  frontal  along 
the  lower  border  of  the  orbit,  meeting  the  first  at  the  middle 
of  the  malar  bone. 

He  worked  down  to  the  bone  through  the  first  incision 
and  separated  the  attachments  of  the  masseter  to  the  malar 
bone.  As  soon  as  the  tense  fascia  hucealis  was  cut  the 
tumor  appeared.  Drawing  the  inferior  maxilla  away  with 
a  speculum,  he  easily  passed  his  finger  between  the  tumor 
and  the  superior  maxilla  through  the  pterygo-maxillary 
fissure  'n\U^  the  Sidieno-maxillary  fossa,  both  of  which  had 
been  enlarged  by  pressure,  and  then  through  the  dilated 
foramen  spheno-palatinum  to  the  cavity  of  the  nose. 


184  EXCISION    OF    JOINTS    AND    BONES. 

A  fine  elevator  and  then  a  fine  keyhole  saw  were  passed 
by  the  same  route,  and  the  superior  maxilla  sawn  through 
horizontally  from  behind  forward,  while  the  left  forefinger, 
passed  through  the  mouth  into  the  })harynx,  covered  the 
point  of  the  saw  and  kept  it  from  striking  against  the  sep- 
tum of  the  nose. 

The  second  incision  was  then  carried  down  to  the  bone 
and  into  the  orbit,  and  the  soft  parts  divided  in  the  angle 
between  the  frontal  and  zygomatic  processes  of  the  malar 
bone. 

The  second  cut  with  the  saw  was  then  made  from  below 
upward  through  the  zygomatic  process  of  the  temporal  and 
the  frontal  process  of  the  malar  bone  to  the  spheno-maxillary 
fissure,  and  thence  across  the  floor  of  the  orbit  to  the  lach- 
rymal bone. 

The  resected  portion  was  thus  left  attached  only  to  the 
nasal  bone  and  the  nasal  process  of  the  frontal  by  its  own 
uninjured  nasal  process.  The  hard  palate  and  alveolar  pro- 
cess had  not  been  touched. 

He  then  passed  an  elevator  under  the  malar  bone  and 
turned  the  piece  slowly  upward  upon  its  connections  as 
upon  a  hinge  until  the  malar  bone  had  nearly  reached  the 
median  line  of  the  face,  and  the  spheno-maxillary  and  nasal 
fossie  were  completely  accessible. 

The  bleeding  was  severe,  but  stopped  spontaneously,  the 
arteria  spheno-palatina  alone  was  tied  at  its  entrance  into 
the  foramen  spheno-palatinum. 

The  bone  was  replaced  and  nicely  adjusted,  its  tendency 
to  rise  being  restrained  by  pressure  until  the  metallic  sutures 
had  been  set  in  the  skin. 


OTHER    METHODS    OF    GAINING    ACCESS    TO    THE    PHARYNX 
THROUGH    THE    NOSE. 

These  may  here  be  described,  although,  properly  speak- 
ing, they  are  not  resections  of  the  superior  maxilla. 

Boeckel  makes  two  transverse  cuts  across  the  nose,  and 
unites  their  extremities  by  a  third  along  its  side.  The  cuts 
are  carried  to  the  bone,  and  the  (juadrilateral  osteo-cutane- 
ous  flap  thus  formed  turned  back  upon  the  cheek,  the  other 


TO    GAIN     ACCESS    TO    TUK    I'UAKYNX.         185 

nasal  process  wliidi   \nnn^  its  base  liaviii;:  first  been   broken 
witli  iia(kl('(l   tbnt'ps,  one  blade  of  wliicli    is   ]»asse(l   into  tbe 

nostril. 

Oilier  turns  the  wliole  nose  downward,  lie  be'^ins  bis 
incision  at  the  ed«ie  of  the  bone  close  l)ehind  tbe  ala  of  tbe 
nose  carries  it  upward  along  its  side  to  the  highest  part  of 
the  depression  between  the  eyes,  then  across  and  down  to 
tlie  corresj)onding  point  on  the  other  side  (Fig.  1)1,  A). 
The  bone  is  sawn  through  in  the  line  of  the  incision,  the 
necessary  liberating  incisions  made  in  the  septum  or  the 
sides,  and  the  nose  turned  down. 

Fig. 'JL 


■^ 


Ollier's  operation  fur  removal  of  a  naso-pharyngeal  polyi..     B.  .^lodification  for  a  very 

large  polyp. 

The  septum  is  pressed  aside,  the  polyp  extracted,  its  base 
of  implantation  scraped,  and  the  nose  replaced. 

A  modilication,  which  is  sometimes  desirable  on  account 
of  the  size  of  the  polyp  or  the  distance  of  its  implantation, 
is  indicated  in  Fig.  91,  B.  The  incision  runs  more  ob- 
liquely backward,  and  a  transverse  one  is  made  from  each 
end  to  the  ala  of  the  nose.  The  bone  is  divided  in  the 
direction  of  the  cutaneous  incisions,  in  the  vertical  one  as 
l)efore  described,  in  the  horizontal  one  by  i)assing  a  fine  saw 
across  the  nostrils  through  holes  made  between  the  bone 
and  cartilages,  and  sawing  backward.  This  line  of  section 
must  be  high  enough  to  avoid  the  roots  of  the  teeth. 

In  some  cases  it  is  sufficient  to  mobilize  the  loivcr  nid  of 
the  )iose  by  an  incision  under  the  lip  in  the  gingivo-labial 

1G» 


186  EXCISION    OF    JOINTS    AND    BONES. 

fold,  and  tlieii  by  carrying  it  and  the  lip  upward  very  free 
access  to  tlie  nasal  fossae  is  obtained. 


EXCISION    OF    T'lE    IXFEIUOR    MAXILLA. 

This  may  be  total  or  partial ;  and  partial  excision  may 
involve  the  removal  of  any  part  of  the  body  of  the  bone  or 
of  the  ascending  ramus.  Partial  excision  of  the  body  may 
sometimes  be  accomplished  through  the  mouth  without  the 
aid  of  a  cutaneous  incision,  or  l)y  an  incision  along  the 
lower  border  of  the  bone  with  or  without  another  at  right 
angrles  to  it  extendinir  toward  or  even  throufrh  the  lip,  or 
by  two  vertical  incisions  downward  from  the  angles  of  the 
mouth  when  only  the  upper  part  of  the  body  of  the  bone  is 
to  be  removed. 

When  the  ascending  ramus  also  is  to  be  resected  the  in- 
cision should  pass  along  the  lower  border  of  the  bone  to  the 
angle  of  the  jaw,  and  then  upward  along  the  posterior 
border  of  the  ramus  to  the  level  of  the  lobule  of  the  ear. 
If  the  incision  is  carried  higher  the  fjicial  nerve  is  neces- 
sarily divided  with  consequent  paralysis  of  the  muscles  sup- 
plied by  it,  a  complication  which  should  be  avoided,  not- 
withstanding the  assertion  of  some  authors  that  the  paralysis 
may  disappear  after  a  time.  The  horizontal  portion  of  the 
incision  should  be  a  little  below  the  border  of  the  bone  in 
order  that  the  cicatrix  may  be  less  conspicuous.  Syme 
removed  the  entire  ramus  with  the  condyle,  without  open- 
ing into  the  cavity  of  the  mouth,  by  an  incision  slightly 
convex  backward  extendins:  from  the  zvcroma  to,  and  a 
little  beyond,  the  angle  of  the  jaw. 

The  principal  danger  is  of  injury  to  the  internal  maxillary 
artery,  which  lies  almost  in  contact  with  the  inner  side 
of  the  neck  of  the  condyle.  The  lingual  nerve  also  is  in 
close  relation  with  the  inner  side  of  the  ramus,  lying  be- 
tween it  and  the  internal  pterygoid  muscle.  Maisonneuve 
introduced  a  modification  of  the  method  of  operating  which 
has  rendered  it  almost  easy  and  has  diminished  the  above- 
mentioned  danger.  It  consists  in  separating  the  attach- 
ments of  the  condyle  by  twisting  and  tearing  out  the  bone 
after  all  the  connections  have  been  divided.     If  this  modifi- 


EXCISION    OF    THE    INFEKIOH     MAXILLA         187 

cation,  which  sounds,  perhaps,  rougher  and  less  surgical 
tlian'  it  really  is,  is  not  adopted,  the  joint  must  he  ap- 
proached from  in  front  so  as  to  av<»id  the  external  carotid, 
which  lies  close  behind  the  hone  in  the  substance  of  the 
parotid.  It  is  sometimes  allowable  to  divide  the  neck  of 
the  condyle,  or  even  the  ramus  below  the  sigmoid  notch, 
with  cutting  pliers,  and  leave  the  upper  fragment  in  place. 

Another  danger  is  in  the  division  of  the  attachments  of 
jXcnio-hvo-Ldossus  muscles  to  the  bone.  The  toncrue,  de- 
j)rived  of  its  support,  falls  back  upon  and  closes  the  glottis. 
As  a  preliminary,  therefore,  to  any  operation  in  which  these 
attachments  are  divided;  a  stout  ligature  should  be  passed 
through  the  tip  of  the  tongue  and  held  by  an  assistant. 
After  the  operation  it  should  be  fastened  to  a  harelip  pin 
in  the  external  incision,  or  to  the  skin  of  the  face  by  a  strip 
of  adhesive  plaster,  and  retained  for  a  couple  of  days,  at 
the  end  of  which  time  the  muscles  will  usually  have  formed 
new  attachments. 

The  bone  should  be  sawn  through  with  a  chain  or  com- 
mon saw,  according  to  circumstances,  or  merely  nicked  with 
the  saw,  and  its  division  completed  with  cutting-pliers. 
The  tooth  occupying  the  proposed  line  of  section  should 
first  be  drawn. 

Ligature  of  one  or  both  carotids  has  been  proposed  and 
performed  as  a  preliminary  operation  to  prevent  excessive 
hemorrhage,  but  it  has  proved  to  be  not  only  unnecessary 
but  ineffectual.  In  Mott's  case  the  main  operation  had  to 
be  adjourned  to  allow  the  patient  to  recover  fi-om  the  shock 
of  the  preliminai-y  one.  In  another  case  in  which  both 
carotids  had  been  tied,  the  main  operation  had  to  be  aban- 
doned on  account  of  hemorrhaore.^  Svme  says  the  pre- 
liminary  ligation  is  unnecessary,  because  the  only  arteries 
that  need  to  be  divided  are  the  facial  and  the  transverse 
branches  of  the  temporal,  bleeding  from  which  can  be  easily 
controlled,  and,  furthermore,  all  the  advantages  offered  by 
ligation  of  the  carotids  can  be  obtained  by  their  temporary 
compression  during  the  operation. 

The  attempt   should  he  made,  when  possible,  to  get  pri- 

^  Mentioned  by  Syme  in  Contributions  to  the  Pathology  and  Prac- 
tice of  Surgery^  Edinb.,  1848,  p.  19. 


188  EXCISION    OF    JOINTS    AND    BONES. 

mary  union  of  the  intra-buccal  wound  and  to  drain  through 
the  external  one.  This  makes  it  easier  to  keep  the  wound 
sweet,  diminishes  the  danger  of  purulent  infection,  and 
avoids  the  risks  incident  to  the  swallowinf;  of  the  decom- 
posing  discharges. 

The  results  of  the  operation  are  usually  very  good,  and 
the  deformity  less  than  might  be  expected.  Subperiosteal 
excision  has  been  followed  by  reproduction  of  the  entire 
bone  with  condyles  and  diarthrodial  cartilages,  and  even 
when  the  periosteum  is  not  preserved  the  cicatrix  becomes 
very  firm  and  fibrous,  and  able  to  support  a  plate  with  arti- 
ficial teeth. 

Resection  of  the  Anterior  Portion  of  the  Body. — This 
may  be  done  by  means  of  a  vertical  incision  in  the  median 
line,  or  of  a  horizontal  one  below  the  free  border  of  the 
bone,  or  from  within  the  mouth  without  any  cutaneous  in- 
cision. 

If  one  of  the  incisions  is  made,  the  external  and  internal 
surfaces  of  the  bone  are  cleared  through  it,  a  tooth  drawn 
at  each  of  the  proposed  points  of  section,  and  the  bone  sawn 
throu2:h. 

If  no  external  incision  is  made,  the  external  surface  of 
the  bone  is  cleared,  beginning  at  the  edge  of  the  gum  or  in 
the  o-iugivo-labial  fold,  accordinor  as  the  i)eriosteum  is  or  is 
not  to  be  preserved,  and  the  lip  drawn  down  under  the 
chin  so  that  the  bone  protrudes  through  the  mouth.  It  can 
then  be  easily  sawn  through  and  freed  from  its  attachments 
on  the  inner  side. 

Resection  of  the  Lateral  Portion  of  the  Body. — The  in- 
cision extends  along  the  lower  border  of  the  jaw  from  its 
angle  nearly  to  the  symphysis,  and  then  is  carried  vertically 
upward  to  the  base  of,  but  not  through,  the  lip.  The  flap 
is  dissected  up,  the  elevator  being  used,  of  course,  if  the 
periosteum  is  to  be  preserved,  the  inner  surfiice  of  the  bone 
cleared  near  the  symphysis  for  the  passage  of  a  chain-saw, 
and  the  section  made  if  possi1)le  at  a  short  distance  from 
the  median  line,  so  as  not  to  disturb  the  insertion  of  the 
genio-hyo-glossus.  This  section  may  be  made  with  a  nar- 
row saw  from  before  backward  if  preferred. 


EXCISION    OF    THE    INFERIOR    MAXILLA 


189 


The  bone  is  then  drawn  dowmvanl  and  outward,  its  inner 
surface  cleared,  and  the  saw  aj)|»lie<l  l)ehind  the  hist  molar 
tooth  or  at  any  suitable  point. 

JicSictf'on  of  till-  Ramus  ond  Half  of  the  Body.  (Fig. 
I>'2.) — An  incision  is  beirun  close  to  the  posterior  border  of 
the  ramus  on  a  level  with  the  lobule  of  the  ear,  carrie<l 
down  to  the  angle  of  the  jaw,  and  thence  along  its  lower 
border  to  the  symphysis,  where  it  is  met,  if  necessary,  by 
a  vertical  one,  beginning  l)elow  the  free  border  of  the  lip  a 
little  to  that  side  of  the  median  line  on  which  the  bone  is 


Fir;.  (t2. 


Kxcision  of  inferior  maxilla. 


to  be  removed.  The  flap  thus  marked  out  is  dissected  up 
from  the  bone  a.s  far  as  can  be  done  without  opening  into 
the  buccal  cavity,  and  the  divided  facial  artery  tied.  The 
inner  surface  of  the  bone  is  then  cleared  in  the  same  man- 
ner, an  incisor  tooth  drawn,  and  the  bone  sawn  through. 

The  jaw  is  then  drawn  downward  and  forward,  the  denu- 
dation of  its  inner  surface  completed  by  dividing  the  attach- 
ment of  the  mucous  membrane  and  of  the  internal  ptery- 


190  EXCISION    OF    JOINTS    AND    BONES. 

goid,  and  the  inferior  dental  nerve  cut  squarely  across  at 
the  point  where  it  enters  the  ))one. 

The  insertion  of  the  temporal  muscle  upon  the  coronoid 
process  is  divided  with  curved  scissors  while  the  jaw  is  forci- 
bly depressed,  or  the  process  itself  is  cut  through  if  it  is  so 
long  that  its  extremity  cannot  be  reached. 

The  remaining  soft  parts  are  carefully  detached  upward 
toward  the  condyle,  the  knife,  or,  better,  the  elevator  or  the 
handle  of  the  scalpel,  being  kept  close  to  the  bone,  and  the 
separation  completed  by  twisting  the  jaw  out. 

Excision  of  the  ivlioJe  of  the  Inferior  Maxilla. — The  in- 
cision is  made  from  the  lobule  of  one  ear  down  to  the  ansjle 
of  the  jaw,  along  the  lower  border  of  the  bone  to  the  other 
angle,  and  then  up  to  the  lobule  of  the  other'  ear.  The 
outer  and  inner  surfoces  of  the  jaw  are  denuded,  the  bone 
sawn  through  in  the  median  line,  and  each  half  removed  as 
before  described. 

In  the  subperiosteal  method  the  incisions  are  the  same, 
except  that  the  vertical  incision  may  be  in  the  median  line, 
since  the  genio-hyo-glossus  and  genio-hyoid  muscles  remain 
attached  to  the  periosteum.  The  attachment  of  the  tem- 
poral muscle  is  not  cut  but  is  freed  with  the  elevator,  as  is 
also  that  of  the  external  pterygoid  to  the  condyle. 


ANCHYLOSIS    OF    THE    JAW. 

The  most  common  cause  of  anchylosis  of  the  jaw  is 
found  in  cicatricial  retraction  or  adhesions  left  behind  by 
intra-buccal  ulceration.  Rizzoli  (1858)  was  the  first  to 
point  out  that  the  proper  aim  of  an  operation  intended  to 
relieve  this  infirmity  should  be  the  establishment  of  a  pseud- 
arthrosis  in  front  of  the  adhesions  or  cicatricial  bands  when 
the  cause  itself  could  not  be  removed.  His  operation  con- 
sisted in  the  division  of  the  inferior  maxilla  behind  the  last 
molar  tooth  by  means  of  a  specially  constructed  osteotome 
introduced  through  the  mouth.  Bony  union  of  the  fracture 
was  then  to  be  prevented  by  motion.  Esmarch  (1859) 
proposed  the  removal  of  a  wedge-shaped  piece  of  the  bone. 


ANCHYLOSIS    OF    THE    .1  A  W .  191 

By  some  siirujcons  tlic  b.-ise  of  tlio  w<.'<]Lje  is  t.-ikcii  tVom  tlie 
alveolar  process,  hy  others  from  tlie  lower  boi'dcr  ot"  the 
jaw.  Dietteiihacli  proposed  to  divide  the  aseendiiig  ramus 
horizontally  from  hefore  backward  by  means  of  a  chisel 
])ass(Ml  thron<;h  the  month  to  the  anterior  border  of  the 
ramus. 

Operation  (removal  of  wedge-shaped  piece). — An  inci- 
sion is  besrun  at  the  aiiiile  of  the  iaw  and  carried  two  inches 
forward  along  the  lower  border.  A  narrow  strij)  of  bone 
is  then  cleared  on  both  sides  up  to  the  edge  of  the  gum,  a 
tooth  drawn  if  necessary,  the  chain-saw  passed  around  the 
bone  through  the  incision,  and  the  section  made.  The  an- 
terior fragment  is  then  depressed  and  })rotruded  through 
the  wound,  and  a  wedge-shaped  piece  from  one-third  to 
one- half  of  an  inch  in  width  at  its  widest  part  cut  oft"  with 
cutting  forceps. 

Excision  of  the  Condyle. — This  may  be  required  for  the 
relief  of  anchylosis  due  to  bony  or  fibrous  union  between 
the  condyle  and  the  temporal  bone.  The  incision  is  begun 
at  the  lower  margin  of  the  zygoma  close  in  front  of  the 
temporal  artery  where  it  adjoins  the  ear,  and  carried  forward 
along  the  zygoma  about  one  and  a  (quarter  inches,  the  tissues 
being  divided  layer  by  layer  until  the  bone  is  reached.  A 
second  incision,  involving  only  the  skin,  is  then  carried 
from  the  centre  of  the  first  directly  downward  for  about  an 
inch.  The  soft  parts  are  next  carefully  separated  with 
knife  and  elevator  from  the  margin  of  the  zygoma  and  the' 
outer  surface  of  the  joint  and  drawn  downward  with  a  hook, 
thus  preserving  the  parotid,  nerves,  and  vessels  from  injury. 
The  neck  of  the  condyle  is  then  freed  by  working  around 
in  front  and  behind  with  a  small  elevator,  keeping  close  to 
the  bone  so  as  to  avoid  injury  to  the  internal  maxillary 
artei'y,  and  finally  divided  with  the  chisel.  If  there  is  bony 
union  between  the  condyle  and  temporal  bone  the  chisel 
must  be  again  used  to  separate  them,  its  edge  being  kept 
directed  somewhat  downward  so  as  not  to  break  thi'ough 
into  the  cavitv  of  the  cranium. 


192  EXCISION    OF    JOINTS    AND    BONES. 


RESECTION    OF    THE    STERNUM. 

Oilier^  reports  the  following  case :  A'ertical  incision  four 
inches  long;  detachment  of  periosteum,  and  removal  of  a 
"  red  vascular  sequestrum  one  and  one-quarter  inches  square, 
adherent  to  the  rest  of  the  bone  only  by  medullary  granu- 
lations." The  adjoining  rarefied  bone  was  gouged  away, 
portions  of  the  internal  plate  being  left  at  a  few  points. 
The  projecting  and  denuded  ends  of  two  costal  cartilages, 
the  fourth  and  fifth,  were  cut  off. 

Three  years  afterward  the  patient  died  of  phthisis,  and 
the  autopsy  showed  reproduction  of  all  the  parts  removed. 


RESECTION    OF    THE    RIBS. 

This  is  l)est  performed  in  those  regions  where  the  bone  is 
covered  by  a  thin  muscular  layer.  In  the  middle  third  of 
the  rib  the  intercostal  artery  lies  in  a  groove  on  the  inner 
side  of  the  lower  border. 

The  incision  should  correspond  in  length  and  direction 
with  the  portion  of  bone  to  be  removed,  and  should  be 
crossed  at  each  end  by  a  short  transverse  one.  The  flaps 
are  then  dissected  up,  the  periosteum  separated  as  far  as 
possible,  a  chain-saw  passed  at  the  limits  of  the  diseased 
portion,  and  the  piece  removed.  Instead  of  the  saw,  cut- 
ting-pliers may  be  used. 

In  Ustlandcrs  operation  for  empyema  (thoraco-plastik), 
in  which  portions  of  several  adjoining  ribs  are  resected  to 
allow  the  chest  wall  to  sink  inward  and  unite  with  the  vis- 
ceral pleura,  the  position  of  the  incision  is  usually  deter- 
mined by  that  of  the  fistula.  The  incision  is  made  along 
the  intercostal  space  occupied  by  the  fistula,  and  the  adjoin- 
ing ribs  resected  as  above  described.  The  limits  of  the 
cavity  are  then  determined,  and  other  ribs  resected,  if  neces- 
sary, through  a  vertical  incision  made  from  the  centre  of 
the  first.  If  the  costal  pleura  is  so  thick  as  to  prevent  the 
attainment  of  the  desired  oljject,  it  must  be  cut  away  from 

'  Traite  de  la  Pvegeneration  des  Os,  vol.  ii.  p.  53. 


KXCISION    OK    THK    CLAVICLE.  193 

a  sufiit'it'nt  p.-nt  (►f'tlie  area  of  resection.  From  tliice  to  six 
ribs  have  been  thus  resected,  in  h-n^tlis  varying  tVoni  one  to 
three  inches.  The  operation  lias  been  restricted  to  the  ribs 
between  the  third  and  eightli,  but  in  one  case  a  snnill  portion 
of  the  clavicle  also  was  removed.  Sometimes  the  tliick(Mied 
visceral  pleura  has  also  been  dissected  off. 


EXCISION    Oi-    Tin:    CLAVlCLi;. 

On  account  of  the  proximity  of  the  large  vessels  of  the 
neck  this  has  been  considered  the  most  dangerous  of  all  the 
excisions.  The  danger,  however,  varies  greatly  with  the 
nature  and  extent  of  the  disease  Avhich  i-enders  the  opera- 
tion necessary.  Thus,  when  there  is  osteitis  with  thicken- 
ing and  loosening  of  the  periosteum,  the  operator  can  easily 
keep  close  to  the  bone,  and  the  danger  of  injury  to  the 
vessels,  as  well  as  of  exciting  diffuse  inflammation  below 
the  deep  fascia,  is  reduced  to  the  minimum.  On  the  other 
hand,  when  caries  has  existed  for  a  long  time,  the  soft 
parts  have  become  infiltrated  and  bound  down,  and  the  bone 
thickened  and  rou«ihened,  the  difficulties  are  immensely 
increased  ;  and  when  the  bone  is  the  seat  of  a  malignant 
tumor,  extending  in  all  directions,  its  removal  may  tax  the 
powers  of  the  most  skilful.  Valentine  Mott  spoke  of  his 
case  as  the  most  difficult  and  tedious  operation  he  had  ever 
witnessed  or  performed;  it  lasted  four  hours,  and  metre 
than  forty  ligatures  were  applied,  including  two  upon  the 
internal  jugular  vein. 

As  only  the  inner  half  of  the  bone  is  in  close  relation 
with  the  vessels,  and  the  danger  is  especially  great  at  the 
sterno-clavicular  joint,  it  is  advisable  first  to  raise  the  outer 
end  of  the  bone  from  its  place  by  opening  its  articulati(m 
with  the  acromion  or  by  dividing  it  a  little  to  the  inner  side 
of  that  joint,  and  then,  after  clearing  the  posterior  surface 
from  without  inward,  to  divide  the  attachments  of  the 
inner  end  while  twisting  the  bone  upward  about  its  long 
axis,  and  keeping  the  edge  of  the  knife  against  it.  When 
this  is  impracticable  the  periosteum  must  be  carefully  sepa- 
rated near  the  middle,  and  the  bone  sawn  through  with  the 

17 


194  EXCISION    OF    JOINTS    AND    BONES. 

usual  precautions  against  injury  to  the  underlying  parts. 
Each  half  is  then  raised  in  turn  and  dissected  out. 

For  the  removal  of  a  tumor  no  fixed  rules  can  be  given. 
In  other  cases  the  directions  are  as  follo^YS : 

Operation. — The  subperiosteal  method  must  be  employed 
throuo-liout.     The  incision  is  made  alono-  the  anterior  sur- 

o  ... 

face  of  the  bone,  and  corresponds  in  length  with  the  portion 
to  be  removed.  A  short  transverse  incision  is  then  made 
at  each  end  of  the  first,  the  flaps  dissected  up,  and  the 
denudation  carried  as  far  as  possible  around  the  bone  al)ove 
and  below. 

The  bone  is  then  freed  at  its  acromial  end,  or  divided 
in  the  middle,  and  the  separation  completed  as  above 
described. 


EXCISION    OF    THE    SCAPULA. 

It  is  impossible  to  lay  down  fixed  rules  for  making  the 
incisions  when  the  operation  is  rendered  necessary  by  a 
tumor  of  the  bone.  They  will  be  determined  by  the  cir- 
cumstances of  the  case  and  especially  by  the  extent  of  the 
disease,  for  while  in  some  cases  the  acromial  end  of  the 
clavicle  must  also  be  removed,  in  others  the  acromion  and 
neck  of  the  scapula  may  be  left  behind. 

Mr.  Holmes^  says:  "The  surgeon  turns  down  appro- 
priate skin-flaps.  .  .  .  When  the  whole  tumor  is  thus 
exposed,  the  muscles  inserted  into  the  vertebral  border  of 
the  bone  should  be  rapidly  divided,  as  also  those  which  are 
attached  to  the  spine  of  the  scapula.  The  tumor  should  be 
lifted  well  up  and  freed  from  its  other  attachments,  com- 
mencing from  its  lower  angle.  The  subscapular  artery  is 
divided  near  the  end  of  the  operation,  and  can  be  held  till 
the  tumor  is  removed,  or  can  be  at  once  tied.  The  liga- 
ments of  the  shoulder  are  then  easily  divided  and  the  mass 
removed." 

Gross"-  made  a  vertical  incision  sixteen  inches  long  down- 
ward from   the  superior  angle  of  the  scapula,  and  circum- 

^  A  Syst.  of  Surgery,  vol,  v,  p.  669. 

"  Gross's  Syst.  of  Surger^^,  vol.  ii.  p.  1078. 


EXCISION    OF    THE    SCAl'ULA.  195 

scribed  mh  oval  portion  hy  a  socoiid  curved  incision,  l>c;:in- 
nin«^  five  inches  below  the  upper  end  of  the  first  and  endin-r 
about  the  same  distance  above  its  lower  end,  and  removed 
the  bone  after  sawing  through  tlie  acromion  and  neck  of  the 
scapula. 

Velpeau'  reconuiiends  three  incisions:  one  along  the  spine 
of  the  scapula,  the  others  starting  from  the  anterior  ex- 
tremity of  the  first  and  i-unning,  one  toward  the  root  of  the 
neck,  the  other  toward  the  axilla  Ijchind. 

Syme  made  two  incisions  crossing  each  other  near  the 
centre  of  the  tumor.  Other  surgeons  have  made  triangular 
or  semilunar  flaps. 

In  January,  LSTS,  Dr.  George  A.  Peters  removed,  at  the 
New  York  Hospital,  the  entire  scapula  for  malignant  disease, 
leaving  the  arm.  He  made  an  incision  along  the  spine  of 
the  scapula,  divided  the  fibres  of  the  deltoid  and  trapezius, 
and  exposed  the  tumor,  which  involved  only  the  acromion 
and  adjoining  portion  of  the  spine.  He  then  made  a  ver- 
tical incision  across  the  centre  of  the  first,  beginninf?  two 
inches  above  it  and  extending  to  the  inferior  angle  of  the 
scapula,  reflected  the  flaps,  dissected  out  the  under  surface 
of  the  bone  from  behind  forward,  separated  the  acromion 
from  the  clavicle  and  humerus,  and  then,  raising  the  lower 
angle  of  the  scapula  toward  the  head,  approached  the 
coracoid  process  from  below,  and  found  no  difficulty  in 
separating  it  from  its  attachments.  Only  two  vessels  re- 
quired ligation,  the  supra-scapular  and  a  large  branch  of 
the  subscapular.  The  operation  was  performed  under  the 
spray,  and  the  wound  treated  antiseptically.  The  result 
was  verv  good ;  six  weeks  afterward  the  wound  had  closed, 
and  the  patient  possessed  a  certain  degree  of  control  over 
the  humeinis. 

Subperiosteal  Excision  of  the  Scapula  (Oilier).  Fi<T^. 
93.  1.  Incision  of  the  Ski^i  and  Muscular  Interstices. — 
An  incision  is  made  along  the  whole  length  of  the  spine  of 
the  scapula,  and  from  its  posterior  extremity  tAvo  others  are 
made,  one  following  the  posterior  border  down  to  the  inferior 
angle,  the  other  running  obliquely  forward  and  u[)ward  for 

'   Medecine  Operatoire,  vul.  ii,  p.  0-">9. 


196 


EXCISION    OF    JOINTS    AND    BONES 


about  an  inch.     A  short  transverse  incision  may  also  be 
needed  at  the  anterior  end  of  the  first. 

2.  Denudation  of  the  Bone. — The  attachments  of  the 
deltoid  and  trapezius  to  the  acromion  and  spine  are  sepa- 
rated, the  periosteum  of  the  posterior  border  of  the  scapula 
divided  in  the  interstice  between  the  rhomboideus  and  infra- 
spinatus, and  the  infra-si>inous  fossa  carefully  denuded.    The 

Fig.  93. 


Excision  of  tlio  .sraimla. 

periosteum  is  very  thin  in  its  lower  third.  The  lower  angle 
is  freed  by  detaching  the  teres  major  and  serratus  magnus, 
the  bone  raised,  and  tlie  subscapularis  detached  from  below 
upward.  If  the  marginal  cartilage  is  not  completely  ossified 
and  united  with  the  bone,  it  should  be  separated  and  left 
adherent  to  the  periosteum. 

The  supra-spinous  fossa  is  then  cleared,  care  being  taken 
not  to  injure  the  supra-scapular  nerve  in  the  supra-scapular 
notch,  but  to  raise  it  up  with  the  periosteum  and  its  fibrous 
sheath.  The  posterior  part  of  the  bone  is  then  carried  up- 
ward and  forward,  and  the  denudation  of  its  under  surfiice 
and  anterior  border  completed. 

If  the  extent  of  the  disease  permits,  the  denudation  should 


RESECTION    OF    THE    HUMERUS.  197 

stop  at  the  neck  of  tlie  scapula,  wliicli  is  tlien  divided  Avitli 
a  cliaiii-saw  or  cutting  f<)rce])S. 

o.  Opening  of  the  Scapulo-liumeral  Joint.  DetaeJunent 
of  the  Articular  Capsule  and  Denudation  of  the  Coraeoid 
Process. — The  acromion  is  next  separated  from  the  clavicle, 
the  scapuLi  turned  up^vard,  the  joint  opened  from  below, 
and  as  the  bone  is  pressed  steadily  u})ward  everything  that 
holds  is  detached  with  an  elevator.  After  the  coraeoid 
process  has  been  thus  separated  from  most  of  its  muscular 
and  ligamentary  attachments,  the  few  that  remain  can  be 
broken  by  twisting  the  bone  away.  In  suitable  cases  the 
coraeoid  process  may  be*  divided  at  its  base  and  left  in 
place,  and  thus  tlie  most  difficult  and  hiljorious  part  of  the 
operation  done  away  with. 

TliC  partial  excisions  of  the  scapuJa  do  not  require  de- 
tailed description.  The  acromion,  spine,  and  posterior 
border  are  reached  by  straight  or  slightly  curved  incisions 
along  the  portion  to  l)e  removed.  A  crucial  or  H  incision 
is  required  at  the  angles. 


RESECTION    OF    THE    HUMERUS. 

The  position  of  the  musculo-spiral  nerve  is  the  most  im- 
portant element  in  this  operation.  In  its  passage  around 
the  posterior  aspect  of  the  humerus  the  nerve  lies  close  to 
the  bone  within  the  sheath  of  the  triceps  muscle,  and  leaves 
the  latter  on  the  outer  side  of  the  arm  to  enter  that  of  the 
supinator  longus  at  its  origin.  In  approaching  the  bone, 
therefore,  on  the  outer  side  near  the  junction  of  the  middle 
and  lower  thirds,  the  operator  should  lay  bare  the  outer 
border  of  the  brachialis  anticus  and  follow  down  within  its 
sheath  to  the  bone. 

Upper  Portion. — Same  incision  as  in  Ollier's  method  of 
excision  of  the  shoulder  carried  further  down  along  the 
outer  edge  of  the  biceps.  The  cephalic  vein  must  be  sought 
for  and  drawn  aside.  Periosteum  and  capsule  divided,  bone 
denuded  and  removed  as  in  excision  of  the  shoulder-joint 
(q.v.). 

Middle  Portion. — Incision  along  the  posterior  border  of 
the  deltoid  and  outer  edge  of  the  biceps.     Outer  border  of 

17- 


198  EXCISION    OF    JOINTS    AND    BONES. 

the  bracliialis  anticus  laid  bare  and  folloAved  down  to  the 
bone.  Division  of  the  periosteum  and  denudation  of  the 
bone  with  especial  care  for  the  safety  of  the  musculo-spiral 
nerve. 

Oilier  prefers  to  seek  the  nerve  and  draw  it  aside.  He 
also  recommends  that  whenever  it  is  ])ossible  to  leave  a  por- 
tion of  the  shaft  connecting  the  extremities  it  should  be 
done,  as  a  precaution  against  shortening  and  the  formation 
of  a  pseudarthrosis.  If  this  is  not  possible  the  chain-saw^  is 
passed  at  two  points,  and  the  intermediate  piece  removed. 

Lower  Portion. — Incision  on  outer  side  of  the  posterior 
aspect  of  the  arm,  between  the  triceps  and  supinator  longus, 
as  in  Ollier's  excision  of  the  elboAV  {q.  v.). " 

Total  Excision. — Combination  of  incisions  for  upper  and 
lower  portions.  After  the  ends  have  been  denuded  of  peri- 
osteum the  middle  portion  can  be  cleared  by  pushing  one 
end  out  through  its  incision  and  peeling  the  periosteum  back 
like  the  finger  of  a  glove  until  the  middle  is  reached.  The 
bone  is  then  sawn  off,  and  the  other  half  removed  in  a  simi- 
lar manner  through  the  other  incision. 


EXCISION  OF  THE  ULNA. 

Longitudinal  incision  along  the  posterior  aspect  of  the 
bone,  joined  at  its  upper  end  by  a  short  one  running  ob- 
liijuely  ujnvard  and  outward  between  the  triceps  and  anco- 
ni>?us.  The  triceps  is  drawn  to  the  inner  side,  and  the 
olecranon  freed.  After  separation  of  the  periosteum  the 
bone  is  sawn  through  in  the  middle,  and  each  piece  is  dis- 
sected out  in  turn. 


EXCISION  OF  THE  RADIUS  (oLLIER). 

An  incision  involving  the  skin  only  is  made  from  the 
styloid  process  of  the  radius  along  the  outer  border  of  the 
forearm  to  the  radio-humeral  articulation.  The  fascia  is 
divided  and  the  posterior  border  of  the  supinator  longus 
found.  By  following  it  toward  the  wrist  the  knife  can  be 
kept  between  it  and  the  extensor  tendons  of  the  thumb, 


KXCISION    OK     MKTACAKI'AL    1U>NES.  191) 

uliicli  (';i!i  tluMi  1»('  (liawn  Icickwiiid  and  sav(Ml  from  injiii'v. 
l*y  following  it  upward  the  interstic-e  Ix'twccii  it  and  tlic  ex- 
teiisores  carpi  radialos  is  found,  throiigli  wliicli  the  operator 
pc'iietratos  to  tlic  radius  now  covered  only  l)y  tlie  suj/inator 
l)revis.  The  latter  nuiscle  is  tlieii  divided  loiiLdtudiiiallv 
aiul  tlie  ])criosteal  sheath  o})ened. 

The  periosteum  is  detached  latei'ally,  the  hone  sawn 
throuii;h  at  its  middle,  and  eaeli  fragment  removed  se[)a- 
rately. 

Parttitl  Excisioui^  of  the  Ulna  and  Radius. — The  incisions 
and  metliods  are  the  saijie  as  those  ahovc  descrihed. 


EXCISION  OF  THE  Min'ACARPAL  BONES  AND  riIALAN(iES. 

The  metacarpal  bones  should  be  exposed  by  a  longitudinal 
incision  along  the  dorsum.  As  the  extensor  tendons  cross 
the  bones  obliquely  this  incision  should  involve  only  the 
skin  at  first,  the  tendon  is  then  drawn  aside,  and  the  incision 
carried  down  to  and  through  the  periosteum,  which  must  be 
retained  when  possible.  It  is  advisable  that  the  joints, 
especially  the  metacarpo-phalangeal,  should  not  be  opened. 

The  bone  is  then  divided  in  the  middle  with  cutting  for- 
ceps  and  each  end  dissected  out,  or  the  gouge  alone  may 
be  used. 

The  after-treatment  is  important.  Extension  must  be 
made  upon  the  corresponding  finger  for  a  long  time  to  keep 
it  from  being  drawn  up  into  the  hand.  In  the  case  of  the 
metacarpal  bone  of  the  thumb  lateral  pressure  must  also  be 
made. 

For  resection  of  a  phalanx  the  incision  should  be  made 
on  the  side  of  the  finger  near  the  dorsum.  For  the  ter- 
minal phalanx  the  incision  should  be  U-shaped,  the  arms 
passing  along  the  sides  of  the  phalanx,  the  curve  around 
its  end. 

Resection  of  the  different  portions  of  the  tluuub,  even  if 
not  subperiosteal,  is  to  be  preferred  to  amputation,  but  the 
contrary  is  true  of  the  phalanges  of  the  other  fingers. 

Lateral  pressure,  by  means  of  splints  or  an  India-rubber 
glovefinger,  and  extension  by  weight  nnist  be  made  to  insure 
the  necessary  length  and  proper  shape  of  the  member. 


200  EXCISION    OF    JOINTS    AND    BONES, 


RESECTION  OF  THE  BONES  OF  THE  I'ELVIS. 

Oilier'  reports  a  case  in  which  he  removed  the  ascending 
ramus  of  the  ischium  and  most  of  the  pubis  for  supi)urative 
ostoo-arthritis  of  these  bones  and  the  pubic  synchondrosis. 
The  incision  was  about  four  inches  Ions;  and  extended  from 
a  fistula  in  the  genito-crural  fold  up  toward  the  pubis.  The 
periosteum  was  detached,  the  ascending  ramus  of  the  ischium 
removed,  and  then  the  ascending  ramus,  body,  and  part  of 
the  horizontal  ramus  of  the  pubis.  The  bone  that  was 
removed  was  eroded  and  rarefied,  but  not  necrotic. 


EXCISION  OF  THE  COCCYX  (oLLIER). 

This  may  be  required  on  account  of  disease  of  the  coccyx, 
or  as  a  preliminary  to  operations  upon  the  rectum.  Oilier 
has  removed  it  for  osteitis.  Simpson  and  Xott  for  the  relief 
of  coccygodynia,  and  Verneuil  in  cases  of  imperforate  anus, 
and  to  facilitate  the  removal  of  cancers  of  the  rectum. 

The  limits  of  the  bone  are  determined  by  the  finger  in 
the  rectum,  and  a  longitudinal  incision  made  through  the 
skin  and  fibrous  covering  of  the  bone,  from  a  quarter  of  an 
inch  above  its  upper  to  the  same  distance  below  its  lower 
end,  and  a  transverse  incision  made  at  the  u})per  end  of  the 
first.     The  posterior  surface  of  the  bone  is  then  denuded. 

The  sacro-coccygeal  articulation  having  been  opened  by 
this  denudation,  its  fibro-cartilage  is  divided,  and  the  cornua 
cleared  on  both  sides.  An  elevator  is  then  passed  through  the 
joint  and  used  as  a  lever  to  force  out  the  coccyx,  peeling  off 
at  the  same  time  the  fibrous  covering  of  its  anterior  surface. 

If  the  sacrum  is  also  diseased,  and  the  gouge  is  used  upon 
it,  it  must  be  remembered  that  the  sacral  canal  extends  to 
its  very  end,  and  is  there  formed  posteriorly  not  of  bone, 
but  of  fibrous  tissue. 

1  De  la  Regeneration  des  Os,  vol.  ii.  p.  180. 


RESECTION     OE    THE    811 A  ET    UE     THE    TIJ'.IA 


201 


RI'ISKCTION   (JV  'I'llK  SHAFT  ol-'  TIIK  I'lOMUK. 

A  loiii»;itu(liii;il  incision  is  inudc  on  tlic  oiHcr  side  in  llic 
groove  hetwcen  the  vastus  extcrniis  and  hiceps,  with  a.  trans- 
verse liberating  incision  ateachcii<l.  Denudation  is  carried 
as  far  arouiul  as  possible,  tlie  cliain-saw  passed  at  each  end 
of  the  diseased  iK)rtion,  and  tlic  denudation  completed  as  llie 
piece  is  raised  from  its  bed. 

In  tlie  case  of  a  child  extension  sliould  be  made,  and  tlie 
lind)  kept  of  the  same  length  as  tlie  otlier;  in  tlie  case  of 
an  adult  tlie  framnents  should  be  broui^ht  nearer  toirether 
as  the  patient  is  older,  and  his  power  of  regeneration  less ; 
and,  in  many  cases,  it  is  better  to  bring  the  fragments  into 
contact.  Shortening  is  less  of  an  infirmity  than  pseudar- 
throsis. 

RESECTION  OF  THE  SHAFT  OF  THE  TIBIA  (oLLIER). 

(Fig.  94.)  A  longitudinjil  incision  is  made  along  tlie  inner 
surface  of  the  tibia  near  its  i)osterior  border.     The  perios- 


FiG.  94. 


llesectiuu  ot  the  tibia.     3IethoiI  uf  placing  tlic  curvctl  elevator  so  as  to  protect  the 

periosteal  ebeatb. 


•202  EXCISION    OF    JOINTS    AND    BONES. 

teiini  is  incised,  ami  tlie  Ijone  denuded.  For  tlie  latter  pur- 
pose it  is  necessary  to  use  a  well-curved  elevator,  because 
the  sharpness  of  the  angles  of  the  bones  makes  it  very 
difficult  to  get  around  them  without  perforating  the  perios- 
teal sheath.  After  the  denudation  is  completed  at  one  point, 
the  curved  elevator  is  passed  behind  the  bone,  and  then  the 
chain-saw  alon^  its  groove.  The  bone  is  divided,  the  ele- 
vator  withdrawn,  and  each  fragment  raised  in  turn  and 
cleared  along  its  posterior  surface  and  boi'ders.  If  the 
periosteum  is  loosely  adherent,  it  may  be  stripped  off  by 
passing  the  elevator  up  and  down  in  the  sheath  behind  the 
bone. 

In  resection  of  only  a  portion  of  the  diaphysis  it  is  better 
to  saw  through  the  l)one  at  each  end  of  the  portion  that  is 
to  be  removed. 

The  bone  is  necessarily  denuded  for  some  distance  be- 
yond  the  proposed  line  of  section,  but  this  distance  may  be 
diminished  by  a  transverse  incision  through  the  periosteum 
at  that  point.  Moreover,  necrosis  of  the  denuded  part 
rarely  follows. 


RESECTION  OF  THE  FIBULA. 

The  lower  portion  of  the  fibula  is  subcutaneous,  its  u})per 
portion  is  covered  by  the  peroneal  muscles.  The  biceps  is 
attached  to  its  head,  and  the  external  popliteal  or  peroneal 
nerve  after  following  the  posterior  border  of  the  tendon  of 
that  muscle  winds  around  the  outer  side  of  the  neck  of  the 
fibula,  and  divides  into  the  anterior  tibial  and  musculo- 
cutaneous, the  latter  of  which  soon  becomes  superficial. 
Sometimes  this  division,  and  even  the  subsequent  ones,  take 
place  as  high  up  as  the  head  of  the  fibula,  and  then  there 
is  danger  of  dividing  some  of  the  l)ranclies  during  resection 
of  the  upper  extremity  of  the  bone,  unless  the  method  indi- 
cated by  Oilier  is  strictly  carried  out.  The  earlier  authors 
considered  the  division  of  this  nerve  unavoidable. 

As  the  upper  tibio-fibular  articulation  communicates  in  a 
large  proportion  of  cases  with  that  of  the  knee,  it  should 
not  be  opened,  except  when  it  shares  in  the  disease.  The 
head  of  the  filnila  should  be  divided  or  froucj^ed  out  in  such 


RESECTION    OF    THE    WIIOl-E    FIHl'LA.         203 

a  wny  us  to  leave  tliis   articulalioii   tovi  rc(l   l)_v  a   tliiii   hut 
complete  plate  of  hone. 

ReBi'rtion  of  the  Upjjrr  Extrftiiity  ot  tlw  FihuUi  (Ollior).' 
— A  loiiL^itiulinal  inci.sioii  is  hegun  an  ineli  ahovc  the  head 
of  the  fihula  at  the  posterior  horder  of  the  ten<lon  of  the 
hiceps,  and  carried  down  a  little  behind  the  bone  along  the 
interstice  between  the  soleus  and  the  ])eroneal  muscles.  The 
incision  should  involve  only  the  skin  and  fascia. 

The  nerve  is  then  sought  for  where  it  passes  around  the 
neck  of  the  fibula,  and  protected  by  two  blunt  hooks  placed 
about  an  inch  apart.  M'hile  thus  protected,  it  is  freed  from 
the  cellular  tissue,  which  binds  it  to  the  bone,  and  then  drawn 
forward  so  as  to  permit  the  division  of  the  periosteum.  This 
division  is  made  on  the  posterior  border  of  the  bone,  and 
carried  downward  as  far  as  is  necessary  in  the  interstice 
between  the  soleus  and  peroneal  muscles. 

The  periosteum  is  then  detached  and  the  bone  removed, 
either  by  dividing  it  at  two  points  with  a  chain-saw  and 
removintr  the  intermediate  portion,  or  bv  dividing  it  at  the 
lower  limit  of  the  disease,  and  twisting  out  the  upper  frag- 
ment, or  by  modifying  the  latter  method  to  the  extent  of 
dividing  the  head  of  the  bone  with  a  sharp  chisel  in  such  a 
manner  as  to  leave  the  tibio-fibular  joint  unopened. 

Resi'rtion  of  the  Loiver  Portion  of  the  Fihula. — Longi- 
tudinal incision  along  the  antero-external  aspect  of  the  bone. 
Denudation  and  removal  of  the  bone  in  the  usual  manner. 
For  other  details,  see  excision  of  the  ankle-joint. 


EXCISION  OF  THE  WHOLE  FIBULA. 

As  the  incisions  for  the  resection  of  the  u|)per  and  lower 
portions  lie  on  opposite  sides  of  the  peroneal  muscles,  they 
cannot  be  made  continuous  with  each  other.  Each  half  of 
the  bone  must  be  removed  separately. 

^  Traile  de  la  Regeneration  des  Os,  p.  2G7. 


204  EXCISION    OF    JOINTS    AND    BONES. 


EXCISION  OF  THE  BONES  OF  THE  FOOT. 

Calcaneum. — Disease  of  the  tarsal  bones  is  apt  to  origi- 
nate in  the  cak-aneo-astragaloid  articulation  and  then  in- 
volve the  calcaneum  mainly,  the  astragalus  being  only 
superficially  aftected.  The  disease  in  the  former  is  usually 
central,  leaving  a  sequestrum  inclosed  in  a  shell  of  rarefied 
vascular  bone,  or  a  cavity  is  formed  within  a  similar  shell 
by  .ulceration  and  discharge  through  one  or  more  fistul^e. 
The  removal  of  the  entire  thickness  of  the  bone  gives  better 
results  than  simple  gouging  out  of  the  diseased  portions, 
evidement  de  Fos,  but  the  anterior  portion  should  if  pos- 
sible be  left,  as  it  favors  reproduction  of  the  bone. 

The  English  surgeons  do  not  usually  employ  the  sub- 
periosteal method,  claiming^  that  the  results  obtained  by 
the  ordinary  method  are  so  good  that  they  are  disinclined 
to  make  any  change.  So  far  as  can  be  judged  from  the 
published  descriptions,  these  results, ,  although  satisfactory 
so  fiir  as  the  restoration  of  function  is  concerned,  are  infe- 
rior to  those  obtained  by  the  subperiosteal  method.  The 
absence  of  the  calcaneum  destroys  the  plantar  arch  and  the 
sightliness  if  not  the  usefulness  of  the  foot,  "svhereas  in  some 
of  Ollier's  subperiosteal  cases  the  new  heel  was  as  prominent 
and  firm  as  that  of  the  other  foot. 

A.  Holmes's  Method. — An  incision  is  commenced  at  the 
inner  edge  of  the  tendo  Achillis,  and  drawn  horizontally 
forward  along  the  outer  side  of  the  foot  to  a  point  some- 
what in  front  of  the  calcaneo-cuboid  articulation.  This 
incision  should  go  down  at  once  upon  the  bone,  so  that  the 
tendon  should  be  felt  to  snap  as  the  incision  is  commenced. 
It  should  be  on  a  level  with  the  upper  border  of  the  os 
calcis.  Another  incision  is  then  made  vertically  across  the 
sole,  commencino-  near  the  anterior  end  of  the  former  inci- 
sion  and  ending  at  the  outer  border  of  the  internal  surface 
of  the  OS  calcis.  The  bone  being  now  denuded  by  throwing 
back  the  flaps,  the  calcaneo-cuboid  and  calcaneo-astragaloid 
joints  are  sought  for  and  laid  open.  The  calcaneum  having 
been  thus  separated  from  its  bony  connections  by  the  free 

•  Holmes,  System  of  Surgery,  vol.  v.  p.  720. 


EXCISION    OF    TTIE    HUNES    OF    THE     FOOT.       205 


Fk;.  !>o 


use  of  tlie  knife,  aiiU'd,  if  iK'^ossary,  by  tlie  k-ver,  lioii- 
f()rc*('[)S,  etc.,  the  soft  parts  are  next  to  he  cleaned  off  its 
inner  side  witli  care,  in  order  to  avoid  tlie  vessels,  and  the 
hone  will  then  come  away. 

1>.  Suhperiosftui/  Mrt'/tod  (OWicr).  Fig.  !>'>,  A. — An  in- 
cision involving  only  the  skin  is  begun  at  the  outer  border 
of  the  tendo  Achillis  about  an 
inch  higher  than  the  tip  of  the 
external  malleolus,  carried  down 
below  the  outer  tuberosity  of 
the  calcaneum  and  then  forward 
and  slightly  upAvard  to.  the  up- 
per ])art  of  the  base  of  the  fifth 
metatarsal.  The  edge  of  the  ten- 
do  Achillis  and  the  ui)per  border 
of  the  plantar  muscles  being 
recosruized,  the  incision  is  car- 
ried  down  to  the  bone,  care  being 
taken  not  to  cut  the  peroneal 
tendons. 

The  posterior  half  of  the  bone 
is  then  denuded  with  an  ele- 
vator, and  the  tendo  Achillis 
detached  and  pressed  to  the 
inner  side.  The  under  surface 
and  posterior  third  of  the  inner 

surface  are  next  cleai-ed,  the  peroneal  tendons  drawn  aside 
with  blunt  hooks,  the  external  lateral  ligament  detached, 
the  anterior  portion  of  the  outer  surface  denuded,  and  the 
calcaneo-cuboid  joint  opened. 

The  interosseous  ligament  is  divided  with  a  narrow  l)is- 
toury,  the  bone  grasped  with  lion-forceps  and  turned  down- 
ward so  as  to  open  the  calcaneo-astragaloid  joints  and  give 
access  to  the  calcaneo-scaphoid  and  internal  lateral  liga- 
ments and  to  the  inner  surface  of  the  bone. 

It  is  difficult,  if  not  impossible,  to  avoid  opening  some  of 
the  tendinous  sheaths  during  the  operation,  but  the  damage 
is  very  much  less  than  that  inflicted  by  the  former  method. 

Resection  of  the  posterior  portion  alone  can  be  accom- 
plished nmch  more  expeditiously.  The  portion  to  be  re- 
moved  is  denuded  and  then  sawn  oft',  either  directly  or  by 

IS 


A.  Excision  uf  the  calc;iiifuin. 
B   Exci.sion  of  the  astragahis. 


206  EXCISION    OF    JOINTS    AND    BONES. 

perforating  the  bone  and  sawing  it  from  above  downward 
with  a  chain-saw. 

Astragalus. — Excision  of  the  astragahis  may  be  rendered 
necessary  by  dislocation,  comminuted  fracture,  or  caries,  or 
it  may  be  made  as  a  preliminary  step  in  excision  of  the 
ankle.  Oilier  considers  this  operation,  under  normal  cir- 
cumstances, the  most  difficult  of  all  excisions.  He  employs 
the  following  method  on  the  cadaver. 

Operation  (Oilier).  Fig.  95,  B. — Curved  incision  across 
the  dorsum  of  the  foot,  with  convexity  directed  forward, 
beginning  on  the  inner  side  at  the  point  where  the  tendon 
of  tlie  tibialis  anticus  crosses  the  tibio-tarsal  articulation, 
running  forward  and  outward  to  the  middle  of  the  scaphoid, 
and  then  backward  to  a  point  a  little  below  the  tip  of  the 
external  malleolus.  This  incision  must  expose  but  not  in- 
volve the  tendons. 

The  extensor  tendons  are  lifted  out  of  their  sheaths  and 
drawn  aside,  the  extensor  brevis  cut  across  or  detached  at 
its  origin,  and  the  neck  and  outer  non-articular  surface  of 
the  astragalus  cleared.  The  capsular  and  ligamentary 
attachments  of  the  bone  to  the  scaphoid  and  tibia  are  sepa- 
rated, the  interosseous  liojament  divided,  and  the  foot  beino; 
turned  inward  the  insertion  of  the  strontr  internal  tibio- 
astrao-aloid  ligament  is  detached.  The  remaininoj  connec- 
tions  are  then  ruptured  by  grasping  the  bone  with  strong 
forceps  and  twisting  it  out. 

Verneuil  thinks  the  operation  is  made  easier  by  sawing 
throuo-h  the  neck  of  the  bone  and  first  removino:  the  head. 

See  also  Yogt's  excision  of  the  ankle,  p.  175. 

When  dislocated  the  astragalus  may  be  easily  removed 
by  a  straight,  curved,  or  crucial  incision  made  over  the 
most  prominent  part,  and  avoiding  vessels,  nerves,  and 
tendons. 

When  badly  shattered^  as  in  gunshot  injury,  the  fragments 
may  be  removed  through  a  longitudinal  incision  between  the 
extensor  tendons  of  the  first  and  second  toes. 

For  simultaneous  removal  of  the  calcaneum  and  astragalus 
see  Osteoplastic  excision  of  the  foot,  p.  170. 


TKlOrillNlNG.  207 

Mi'tatitrstd  Bours  and  J*/ial<uit/ei<. — A  nictjitarsal  boiic 
sliould  l>e  exposed  ])y  an  iiieisioii  along  the  dorsum  involv- 
ing oidy  the  skin  ;  the  tendon  is  then  drawn  aside,  the 
periosteum  divided,  the  bone  denuded,  sawn  through,  and 
removed.  Whenever  possible,  the  upper  extremity  of  the 
bone  should  be  left. 

For  the  first  and  fifth  metatarsals  it  is  better  to  make  the 
incision  more  u})on  the  side  than  upon  the  dorsum. 

If  the  corresponding  toe  is  to  be  preserved,  extension 
must  be  made  upon  it  for  a  long  time,  in  the  manner  and 
for  the  reasons  mentioned  under  excision  of  the  metacarpal 
bones. 

The  phalanges  and  their  articulations  are  best  excised  by 
lateral  incisions. 

TREPHINING. 

TrepMniiK/  of  the  Cranium  may  be  undertaken  for  the 
evacuation  of  an  intra-cranial  abscess  or  hemorrhagic  effu- 
sion, or  for  the  removal  of  a  suspected  tumor  of  the  bone 
or  meninges,  or  for  the  cure  of  epilepsy,  or  after  fracture 
to  raise  depressed  portions  of  the  bone.  In  all  except  the 
latter  case  the  advisability  of  the  operation  is  greatly 
diminished  by  the  difficulty  of  determining  the  point  at 
which  the  trephine  should  be  applied.  Among  the  more  or 
less  trustworthy  indications,  according  to  which  the  surgeon 
must  make  his  selections  of  this  point,  may  be  mentioned : 
the  history  of  an  injury  more  or  less  recent,^  with  or  without 
pain  and  inflammation  of  the  soft  parts  (Pott's  puffy  tumor) 
at  the  point  where  the  injury  was  received,  or  at  one  dia- 
metrically opposite;  constant,  well-localized  pain  at  any  one 
point ;  injury  over  the  course  of  one  of  the  larger  arteries 
with  rapidly  supervening  symptoms  of  compression,  func- 
tional disturbance  of  certain  groups  of  motor  nerves. 

The  results  obtained  by  certain  physiologists  in  their 
efforts  to  determine  the  location  of  motor  centres  in  the  cor- 
tex of  the  brain  have  inspired  the  hope  that  the  injured  or 
compressed  portion  of  the  brain  might  be  localized  exactly 
in  any  givTn  case  by  consideration  of  the  muscles  or  groups 

1  In  Dui.uytren's  ca.=e  there  was  no  sign  of  the  abscess  until  ten 
years  after  the  receipt  of  the  injury. 


208  EXCISION    OF    JOINTS    AND    BONES. 

of  muscles  paralyzed.  This  hope  has  been  in  })ai-t  realized 
and  surgical  interference  has  been  successfully  based  upon 
paralytic  svniptoms  in  fracture  of  the  cranium,'  abscess  of 
the  brain, "^  and  tumor  of  the  brain. ^ 

As  the  motor  centres  which  Broca,  Ferrier,  liitzig,  and 
other  physiologists  claim  to  have  localized  lie  under  the 
anterior  half  of  the  parietal  bone  and  along  or  near  the 
fissure  of  Kolando,  and  as  these  are  the  only  ones  Avhich  it 
has  been  proposed  to  seek,  it  is  perhaps  desirable  that  direc- 
tions should  be  mxen  for  findino-  this  fissure. 

According  to  Lucas-Championniere^  the  fissure  of  Kolando 
corresponds  to  a  line  drawn  from  a  point  on  the  sagittal 
suture  five  and  a  half  centimetres  posterior  to  the  bregma 
(junction  of  the  sagittal  and  coronal  sutures),  forward  and 
outward  to  a  point  seven  centimetres  l)ehind  and  three  cen- 
timetres above  the  external  angular  process  of  the  frontal 
bone.  According  to  Pozzi^  the  starting-point  of  this  line 
should  be  only  four  and  three-quarters  centimetres  behind 
the  bregma. 

The  line  may  be  more  simply  described  as  the  hypothe- 
nuse  of  a  right-angled  triangle  whose  base  is  the  upper  half 
of  a  line  drawn  from  the  bregma  to  the  meatus  auditorius 
externus,  and  whose  perpendicular  extends  two  inches  back- 
ward from  the  bregma  along  the  median  line. 

The  bregma  is  situated  at  the  point  where  a  vertical  plane 
passing  through  both  external  auditory  canals  intersects  the 
sagittal  suture  when  the  head  is  held  exactly  upright. 

Whenever  it  can  be  avoided,  the  trephine  should  not  be 
applied  over  a  sinus  or  the  middle  meningeal  artery  near 
the  anterior  inferior  angle  of  the  parietal  bone.  Bleeding 
from  a  sinus  may  be  arrested  by  plugging  it  with  antiseptic 
gauze,  but  a  fatal  result  is  likely  to  follow.  The  middle 
meningeal  artery  lies  enveloped  in  the  thickness  of  the  dura 
mater,  adhering  to  it  so  closely  that,  when  cut,  its  walls 
cannot  retract  sufiiciently  to  arrest  hemorrhage.  For  the 
same  reason  it  is  very  difficult  to  apply  a  ligature  to  this 

^  Lucas-Championniere,  La  trepanation  guid^e  par  les  localisations 
cerebrales,  1878. 

2  Stimson,  Archives  of  Medicine,  April,  1881. 

3  Bennett  and  Grodlee,  Lancet,  1885,  i.  p.  23. 

*  Bulletin  de  la  Societe  de  Chirurgie,  1877,  p  121. 
5  Archives  Gen.  de  Med.,  Ayril,  1877,  p.  4')0. 


TKEIMl  INING. 


209 


vessel,  and,  as  tlie  actual  cautery  cannot  1)C  safely  used,  the 
lu'st  means  of  st()p})inLr  the  flow  of  hlood  is  that  proposed  hy 
Tillaux,  of  seizing  the  vessel  and  dura  mater  with  s})ring 
forceps,  and  keeping  it  thus  compressed  for  twenty-four  or 
forty-eight  hours. 

The  {nstnuih'7}ts  used  in  trephining  are  a  stout  knife, 
periosteum  elevator,  trephine,  and  a  screw-pointed  elevator 
which  is  intended  to  be  screwed  into  the  hole  made  by  the 
centre-pin  of  the  trephine,  and  used  to  lift  out  the  circular 
piece  of  bone  after  it  has  been  sawn  through. 

Operation. — A  crucial,  V  or  T-shaped  incision,  one  and  a 
half  to  two  inches  long,  is  made  through  the  soft  parts 
down  to  the  bone,  and  the  flaps,  including  the  pericranium, 
raised  by  means  of  the  periosteum  elevator.  The  iirobability 
of  a  reproduction  of  the  bone  is  increased  by  preserving  the 
connection  of  the  pericranium  with  the  soft  parts. 


Fio.  96. 


Fig.  97. 


\ 


L 


*^  ^.  i*.r***A 


Trephine. 


Hev's  saw. 


The  centre-pin  of  the  trephine  having  been  protruded 
one-sixteenth  of  an  inch,  and  fastened  in  its  place  by  the 
binding  screw  on  the  side,  it  is  forced  by  to-and-fro  rotary 
movements  upon  its  point  into  the  bone  at  the  place  selected, 
and  these  movements  continued  until  the  circular  edge  of 
the  trephine  has  cut  a  groove  sufficiently  deep  to  insure  its 
steadiness  without  the  aid  of  the  pin,  which  must  then  be 
withdrawn  so  as  to  avoid  injury  by  it  to  the  dura  mater. 
The  hole  made  by  the  pin  is  then  enlarged,  and  made  to  fit 
the  point  of  the  screw-pointed  elevator  so  that  this  instru- 
ment can  be  applied  afterward  without  making  too  much 
pressure  upon  the  loose  disk  of  bone. 

18* 


210  EXCISION    OF    JOINTS    AND    BONES. 

The  rotary  movements  are  repeated  very  cautiously,  and 
all  parts  of  the  groove  frecpiently  examined,  as  its  depth 
increases,  -with  a  probe,  pen,  or  quill  tooth]  >ick,  so  as  to  have 
timely  notice  of  complete  perforation.  The  teeth  of  the 
trephine  must  be  freed  from  the  bone  dust  from  time  to  time 
by  means  of  a  brush  or  by  dipping  the  instrument  into 
water.  If,  as  is  usually  the  case,  perforation  takes  place 
upon  one  side  of  the  groove  before  it  does  upon  the  other, 
the  trephine  must  be  slightly  inclined  so  as  to  act  only  upon 
the  unsawn  portion,  or  the  elevator  may  be  used  to  lift  out 
the  disk,  breakins:  the  thin  shell  which  remains. 

If  the  removal  of  a  much  Jaryer  piece  of  hone  is  desired 
the  trephine  should  be  apj^lied  successively  at  two,  three,  or 
more  points,  and  the  intervening  portions  sawn  through 
with  a  Hev's  saw  (Fis:.  97). 

In  a  case  of  depressed  fracture  the  trephine  must  l)e 
applied  to  the  sound  bone  in  such  a  manner  as  to  overlap 
the  edge  of  the  fracture.  The  depressed  portion  is  after- 
ward raised  by  means  of  an  elevator  passed  through  the 
opening  left  at  the  edge  of  the  sound  bone  by  the  removal 
of  the  incomplete  disk. 

In  puncturing  for  a  deep-seated  cd>s<-ess  a  grooved  knife 
or  a  trocar  is  to  be  preferred  to  the  ordinary  flat  blade. 

Frontal  Sinus. — As  the  walls  of  the  frontal  sinus  are  not 
parallel  to  each  other,  Larrey  has  proposed  to  use  two  tre- 
phines of  different  diameters,  the  larger  for  the  outer,  the 
smaller  for  the  inner  table. 

Antrum. — A  very  small  trephine  should  be  used,  and, 
in  order  to  avoid  a  scar,  it  should  be  applied  through  the 
mouth  after  dividinfr  the  dndvo-labial  fold,  and  dissecting 
up  the  soft  parts  as  far  as  to  the  infra-orbital  foramen,  just 
below  and  to  the  outer  side  of  which  the  opening  into  the 
antrum  should  be  made. 

The  antrum  may  also  be  opened  by  drawing  the  first  or 
second  molar  tooth,  and  enlarging  its  socket  with  a  drill. 

No  additional  directions  are  needed  for  trephining  the 
fiat  hones  or  the  eptipJiyscs  (f  the  Jong  ones. 


PAllT   Y. 
Ma  i;OTOMV  AND  TENOTOMY. 

DIVISION  AND  RESECTION  OF  NERVES. 

Division  of  a  nerve,  of  sensation,  or  even  of  a  mixed 
nerve  in  extreme  cases,  may  be  required  for  the  relief  of 
neuralgic  pain.  It  is  seldom  that  simple  division  is  more 
than  temporarily  sufficient.  At  least  half  an  inch  of  the 
trunk  of  the  nerve  should  be  excised,  and,  as  additional 
security  against  reunion,  the  end  of  the  distal  segment  may 
be  bent  l)ack  upon  itself  Prof.  Weir  ^litchelP  has  seen 
severe  constant  pain  follow  the  bending  back  of  the  end  of 
the  proximal  segment. 

supra-orbital  nerve. 

The  frontal  nerve,  main  l)ranch  of  the  first  division  of 
the  trigeminus,  divides  just  behind  the  upper  margin  of  the 
orbit  into  the  supra-orhital  and  supra-trochlear  nerves ; 
both  branches  are  distributed  to  the  forehead,  the  former 
emerging  from  the  orl>it  through  the  supra-orbital  notch  or 
foramen,  the  latter  a  little  nearer  the  nose.  The  former  is 
much  the  larger  and  more  important  of  the  two,  the  latter 
supplying  only  a  narrow  strip  of  integument  near  the  me- 
dian line.  The  supra-orbital  notch  or  foramen  is  found  at 
the  junction  of  the  inner  and  middle  thirds  of  the  supra- 
orbital arch,  or  a  little  to  the  inner  side  of  the  junction. 
When  it  is  a  notch  it  can  be  readily  felt  through  the  skin, 
and  is  then  an  important  guide  in  the  operation. 

The  nerve  may  be  divided  subcutaneously  after  its  emer- 
gence from  the  notch,  or  it  may  be  exposed  by  a  transverse 
incision  above  or  l)elow  the  eyebrow. 

^  Oral  communication. 


212 


NEUROTOMY  AND  TENOTOMY. 


Subcutaneous  Division. — A  tenotomy  knife  is  entered 
between  the  eyebrows  midway  between  tlie  nerve  and  the 
median  line,  and  passed  horizontally  beneath  the  skin  until 
its  point  has  passed  beyond  the  nerve.  Its  edge  is  then 
turned  backward  and  pressed  against  the  bone,  and  the 
nerve,  Ivino:  between  it  and  the  bone,  divided  bv  with- 
drawinfr  the  knife.  Or  the  knife  mav  be  entered  at  the 
same  point,  but  passed  close  to  the  bone  instead  of  just 
under  the  skin,  its  edge  turned  downward  toward  the 
margin  of  the  orbit,  and  the  nerve  divided  by  sweeping 
the  knife  downward  across  the  mouth  of  the  supra-orbital 
foramen. 

Excision  of  a  Portion  of  the  Nerve. — A.  Above  tlie  Eye- 
brow.    (Fig.  08,  A.) — An  incision  one  to  one  and  a  half 

Fig   0^ 


A,  B.  Resection  of  supra-orbital  nerve.     C   Resection  of  superior  maxillary  nerve. 

inches  long  is  made  just  above  and  parallel  to  the  eyebrow, 
its  centre  corresponding  to  the  position  of  the  nerve.  This 
incision  is  carried  down  to  the  bone,  the  distal  end  of  the 
nerve  recognized,  seized  with  forceps,  dissected  out,  and 
cut  off. 

B.  Below  the  Eyebroiv.     (Fig.   98,  B.) — The  eyebrow 
])eino:  drawn  up  and  the  evelid  down,  the  sur<T:eon  makes  an 

oil  c 

incision  one  to  one  and  a  half  inches  in  length  along  the 
edge  of  the  supra-orbital  arch,  dividing  successively  the  skin, 
orbicular  muscle,  and  tarsal  liiiament.     He  then  seeks  the 


S  U  r  E  K  I  O  K    M  A  X  1  L  L  A  l{  V    NERVE.  213 

iicrvo  ill  till'  iiuteli,  traces  it  )»ack  as  far  as  nccossary,  uliik' 
(lepressin;;  the  eve  and  levator  palpel^ne  with  a  retractor, 
and  cuts  out  a  })ortion  Avith  curved  scissors. 

Supra-tt'ochh'dr  Ncrtw. — Koiiig  resected  this  nerve  by 
making  a  curved  incision  under  tlie  eyebrow  at  tlie  u})per 
inner  edi^e  of  the  orbit,  and  seekinii;  tlie  trochlea  and  the 
superior  oblique  muscle.  On  making  the  latter  tense  with 
a  hook  the  two  fine  nerves  became  visible,  were  seized  with 
forceps,  and  resected. 

SUPERIOR  MAXILLARY  NERVE. 

After  leaving  the  cavity  of  the  cranium  by  the  foramen 
rotundum,  the  superior  maxillary  nerve  crosses  the  spheno- 
maxilhiry  fossa,  traverses  the  infra-orbital  canal,  and  ap- 
pears upon  the  face  at  the  infra-orbital  foramen,  where  it 
at  once  divides  uj)  into  numerous  branches  distributed  over 
the  cheek,  nose,  lip,  and  lower  eyelid.  Within  the  infra- 
orbital canal  it  gives  oif  the  anterior  dental  branch,  and 
posterior  to  this  canal  it  gives  off  the  posterior  dental,  and 
through  branches  to  the  spheno-palatine  ganglion,  the  pala- 
tine nerves  distributed  to  the  palate  and  nasal  fossa.  The 
point  at  which  the  nerve  should  be  divided  will  vary  accord- 
ing to  the  region  affected,  but  in  this,  as  in  other  cases, 
simple  division  has  usually  proved  insufficient,  and  it  has 
been  found  necessary  to  excise  all  that  portion  of  the  trunk 
which  lies  in  the  canal.  Sometimes  the  nerve  has  been 
cut  above  the  branches  goino:  to  the  f^aufrlion,  and  the  latter 
torn  out  forcibly. 

The  roof  of  the  infra- orbital  canal  is  composed  in  its  pos- 
terior half  of  fibrous  tissue,  in  its  anterior  half  of  thin  bone 
which  becomes  thicker  as  it  approaches  the  margin  of  the 
orbit.  The  infra-orbital  foramen  lies  directly  above  the 
second  bicuspid  tooth  and  from  one-quarter  to  one-half  an 
inch  below  the  margin  of  the  orbit.  The  nerve  is  accom- 
panied on  its  passage  through  the  canal  by  the  infra-orbital 
artery. 

A.  Division  of  the  Nervr  on  the  Face. — This  may  be 
done:  (1)  subciitaneousli/ ;  (2)  throw fh  the  mouth;  (3)  hy 
an  external  inrision. 


214  NEUROTOMY    AND    TENOTOIMY. 

1.  Sichcufaneoush/. — A  tenotomy  knife  is  entered  about 
an  inch  to  the  outer  side  of  the  foramen,  carried  below  it 
into  the  canine  fossa,  hugging  the  bone,  and  then  swept 
upward  along  the  surface  of  the  bone  so  as  to  divide  the 
nerve  close  to  the  foramen,  the  lip  being  drawn  downward 
and  forward  to  make  the  tissues  tense. 

2.  Through  the  3Iouth. — An  incision  is  made  in  the 
gingivo-labial  fold  and  the  soft  parts  dissected  away  from 
the  bone  until  the  nerve  is  reached  and  divided.  Guerin 
advises  that  a  small  portion  of  the  distal  end  be  excised. 

3.  JB^  External  Incision. — The  incision  may  be  trans- 
verse, oblique,  or  curved  ;  it  is  only  necessary  that  its  centre 
should  correspond  to  the  foramen.  The  tissues  are  divided 
successively  until  the  bone  is  reached  and  the  nerve  found 
either  by  following  up  one  of  its  branches  or  by  seeking  it 
at  its  point  of  emergence. 

B.  Resection  of  the  Infra-orhital  Portion  (Tillaux^). 
Fig.  98,  C. — A  vertical  incision  is  made  along  the  side  of 
the  nose  from  the  lachrymal  tubercle  or  the  bony  ridge  of 
the  nasal  process  of  the  superior  maxilla,  Avhich  is  con- 
tinuous with  the  lower  edge  of  the  orbit,  down  to  the  ala  of 
the  nose.  A  second  horizontal  one  is  then  begun  at  the 
upper  portion  of  the  first  and  carried  outward  along  the 
lower  maro'in  of  the  orbit  bevond  its  centre.  These  inci- 
sions  should  involve  all  the  soft  parts  down  to  the  bone. 
The  lower  flap  is  dissected  up,  the  nerve  found,  and  a  silk 
ligature  throAvn  around  it  close  to  the  foramen. 

The  upper  flap  is  then  raised,  together  with  the  lower 
eyelid  and  eyeball,  exposing  the  floor  of  the  orbit  as  far 
back  as  possible,  upon  which  the  infra-orbital  canal  can  be 
recognized  as  a  grayish  line  running  obliquely  backward 
and  inward. 

The  canal  is  opened  with  a  knife  or  chisel,  the  nerve 
isolated  from  the  artery,  raised  from  its  bed  with  a  small 
hook,  and  dissected  out  as  fiir  back  as  may  be  considered 
necessary.  It  is  then  divided  with  curved  scissors,  and  the 
distal  portion  drawn  out  by  means  of  the  ligature  applied 

^  Traite  d'Anat.  Topographique,  p.  310,  and  Bull,  de  la  Soci^te  de 
Chiriirgie,  1878,  p.  413. 


SUPERIOR    MAXILLARY    NERVE.  215 

to  it  in  tlic  boiriiinin^.      Tiie  Icngtli  of  tlie  portion   removed 
by  Tillaiix  >v;is  six  eeutinietres. 

Dolheau'  divided  tlie  nerve  with  eiirved  scissors  on  tlic 
central  side  of  the  branches  <2:oin<^  to  tlie  splieno-pahitine 
o^anglion,  and  tore  out  tlie  ganglion  by  drawing  upon  the 
nerve. 

Mahjidgncs  Method. — I*ass  a  stout  tenotome  along  the 
floor  of  the  orbit  for  nearly  an  inch  in  the  direction  of  the 
nerve ;  cut  transversely  with  its  point  through  the  Hoor  of 
the  orbit,  the  bone  being  thin  will  offer  no  resistance.  This 
divides  both  canal  and  nerve.  Expose  the  nerve  at  the 
infra-orbital  foramen  by  a  simple  transverse  incision,  seize 
it  with  forceps  and  tear  it  out  of  the  canal. 

The  first  part  of  this  operation  has  been  modified  by  Von 
Langenbeck  and  Hueter  as  follows:  A  strong  tenotome  with 
slightly  blunted  point  is  entered  close  below  the  external 
palpebral  ligament  and  pushed  backward  and  downward 
along  the  outer  wall  of  the  orbit  until  its  point  is  felt  to 
leave  the  bone  and  enter  the  fissure  ;  its  edge  is  then  turned 
forward  against  the  sharp  border  of  the  orbital  i>rocess  of 
the  superior  maxilla  and  made  to  scrape  along  it  as  the 
knife  is  brought  forward. 

Lilekes  3Iethodr — An  incision,  beginning  one  centimetre 
above  the  outer  angle  of  the  eye  and  close  behind  the  margin 
of  the  orbit,  is  carried  downward  and  slightly  forward  across 
the  malar  bone,  dividing  its  periosteum  ;  from  its  lower  end 
a  second  incision  is  carried .  backward  and  forward,  termi- 
nating over  the  outer  surface  of  the  zygoma  about  a  quarter 
of  an  inch  behind  its  junction  with  the  malar  bone.  This 
bone  is  next  divided  in  the  line  of  the  first  incision  by 
means  of  a  chain-saw,  after  preliminary  division  of  the  soft 
parts  and  periosteum  on  its  under  and  inner  surface  with  a 
small  knife,  and  then  severed  from  the  zygoma  with  cutting- 
pliers.  The  attachments  of  the  masseter  to  the  intermediate 
piece  are  then  separated,  and  the  flap  of  bone  and  soft  parts 
raised  with  a  sharp  hook. 

If  necessary,  some  of  the  anterior  fibres  of  the  temporal 
muscle  should  now  be  divided  in  order  to  expose  the  spheno- 

^  Oral  communication. 

■^  Deutsche  Zeitschrift  fiw  Chirurgie,  voL  4,  p.  322. 


216  NEUROTOMY    AND    TENOTOMY. 

maxillary  fossa  tliorouglily,  the  fat  occupying  the  fossa 
pressed  backward  with  a  retractor,  and  tlie  spheno-maxil- 
larv  fissure  recognized  Avith  a  probe.  The  nerve  and  artery 
can  be  distinguished  by  the  difference  in  their  course,  the 
former  running  downward,  outward,  and  forward,  the  latter 
upward,  inward,  and  forward.  The  nerve  is  seized  with 
forceps  and  divided  with  a  tenotome  well  forward  in  the  fis- 
sure, and  then  again  with  scissors  as  near  as  possible  to  the 
foramen  rotundum.  The  flap  is  then  put  ])ack,  and  the 
wound  drained  at  its  lower  angle. 

An  objection  to  this  method  is  that,  in  consequence  of  its 
interference  with  the  masseter  and  temporal  muscles,  the 
mouth  subsequently  cannot  be  freely  opened.  Lossen  and 
Braun^  proposed  to  avoid  this  difficulty  by  leaving  the  at- 
tachments of  the  masseter  untouched  and  turning  the  flap 
downward  instead  of  upward,  after  making  the  second  inci- 
sion from  the  upper  end  of  the  first  instead  of  from  its  lower 
end,  and  separating  the  temporal  fascia  from  the  malar  bone. 
Czerny^  has  employed  this  modification  five  times  with  good 
results. 

If  wounded  vessels  cannot  be  seized  and  tied,  the  hemor- 
rhage must  be  arrested  by  plugging  with  antiseptic  gauze. 


INFERIOR  DENTAL  NERVE. 

This  nerve  may  be  divided  (A)  after  its  exit  from  the 
dental  canal,  (B)  in  the  canal,  (C)  before  its  entrance  into 
the  canal.  The  nerve  enters  the  canal  by  the  inferior 
dental  foramen  on  the  inner  side  of  the  ascending  ramus  of 
the  lower  jaw  at  the  level  of  the  crowns  of  the  lower  teeth  ; 
the  canal  runs  obliquely  downward  and  forward  just  below 
the  alveoli,  and  the  nerve  emerges  through  the  mental  fora- 
men which  lies  midway  between  the  alveolar  process  and  the 
lower  margin  of  the  jaw  below  the  second  bicuspid  tooth. 

A.  At  the  Mental  Foramen. — An  incision  is  made  in  the 
o-ino-ivo-labial    fold  above  the  foramen,   and  the  soft    parts 

'  Centralblatt  fur  Chirurgie,  1878,  pp.  65  and  148. 
2  Ibid.,  1882,  p.  249. 


INFERIOR    DENTAL    NERVE.  217 

dissected  oft'  until   the  nerve  is   leuelied,  usually  about  one- 
third  of  an  ineh  below  the  bottom  of  the  foM. 


B.  WltJiiii  till'  Canal. — An  incision  is  made  through  the 
skin  down  to  the  bone  along  the  course  of  the  nerve  in  front 
of  the  masseter,  the  periosteum  raised,  and  the  canal  opened 
with  a  chisel  or  small  trephine.  After  removal  of  the  outer 
table  of  the  b<tne  the  nerve  is  easily  found  in  the  canal  and 
divided. 

Or  the  canal  may  be  opened  at  two  points  and  the 
intermediate  portion  of  the  nerve  excised. 

C.  Before  its  Entry  into  the  Canal. — 1.  From  ivithin 
the  mouth.  The  mouth  being  held  widely  open  and  the 
commissure  of  the  lips  drawn  backward  and  outward,  an 
incision  extending  from  the  last  upper  to  the  last  lower 
molar  tooth  is  made  one-third  of  an  inch  on  the  inner  side 
of  the  sharp  anterior  border  of  the  coronoid  process,  and 
carried  through  the  mucous  membrane  to  the  tendon  of  the 
temporal  muscle. 

The  surgeon  passes  his  finger  into  the  incision  and  along 
the  inner  surface  of  the  bone,  between  it  and  the  internal 
pterygoid  muscle,  until  he  touches  the  bony  point  which 
•  marks  the  orifice  of  the  canal.  Passincr  a  blunt  hook  along 
the  finger,  he  raises  the  nerve  upon  it,  isolating  it,  if  possi- 
ble, from  the  accompanying  artery,  and  divides  it  with  blunt- 
pointed  scissors  or  knife.  Or,  without  introducing  the 
finger,  the  hook  may  be  passed  back  beyond  the  nerve,  its 
point  constantly  in  contact  with  the  bone,  then  rotated  in- 
ward so  as  to  carry  its  point  across  and  behind  the  nerve, 
and  then  withdrawn. 

2.  Through  the  cheek.  A  curved  incision  is  made  around 
the  angle  of  the  jaw  or  around  the  lower  anterior  insertion  of 
the  masseter  and  carried  through  to  the  bone  along  its  lower 
portion ;  then  with  elevator  and  knife  the  muscle  is  detached 
from  below  upward,  and  the  flap  raised  with  a  hook  until 
the  level  of  the  inferior  dental  foramen  is  reached.  The 
bone  is  then  cut  away,  with  a  chisel  or  small  trephine  and 
the  nerve  exposed  and  excised 

Or  a  vertical  incision  may  be  made  through  the  skin  and 
fascia,  the  fibres  of  the  masseter  separated  and  the  bone  thus 

19 


218  NEUROTOMY    AND    TENOTOMY. 

exposed.  Dr.  AV.  T.  Bull  tells  me  he  found  tliis  method 
very  satisfactory.  It  caused  no  facial  paralysis,  and  the 
wound  healed  kindly. 

BUCCAL  NERVE. 

The  buccal  nerve,  a  branch  of  the  inferior  maxillary,  is 
not  infrequently  the  seat  of  painful  and  persistent  neuralgia. 
It  is  best  approached  throuLdi  the  mouth  l)y  the  following 
method : 

The  surgeon  places  his  finger-nail  upon  the  outer  lip  of 
the  anterior  border  of  the  ascending  ramus  of  the  lower 
jaw  at  its  centre,  and  divides  in  front  of  this  border  the 
mucous  membrane  and  the  fibres  of  the  buccinator  verti- 
cally. He  then  seeks  for  the  nerve,  separating  the  tissues 
with  a  director,  and  divides  it. 


LINGUAL  NERVE. 

Division  of  this  nerve  may  be  required  for  the  relief  of 
pain  in  cases  of  carcinoma  of  the  tongue. 

When  the  mouth  is  opened  widely  the  ptery go-maxillary 
licrament  can  be  readilv  seen  and  felt  as  a  prominent  fold 
behind  the  last  lower  molar,  and  the  lingual  nerve  can  be 
felt  just  below  the  attachment  of  the  ligament  on  the  inner 
side  of  the  lower  jaw,  close  to  the  bone  below  the  last  molar 
tooth. 

The  tongue  should  be  drawn  aside  by  an  assistant,  the 
mucous  membrane  divided  for  about  an  inch  parallel  to  the 
margin  of  the  alveolar  process,  beginning  at  the  last  molar 
tooth  over  the  position  of  the  nerve,  or,  according  to  Chau- 
vel,^  one-fifth  of  an  inch  from  the  attachment  of  the  mucous 
membrane  to  the  side  of  the  tongue.  The  nerve  is  then 
readily  found  in  the  submucous  tissue,  raised  upon  a  hook 
and  divided,  or  a  portion  excised. 

3Ioore8  Method. — Mr.  Moore  has  employed  the  following 
method  successfully  in  five  cases.     He  cuts  the  nerve  about 

^  Precis  d'Openitions  de  Chirurgie,  p.  435. 


TENU'lOMY.  219 

lialf  ail  iiicli  from  tlie  last  molar  tooth,  at  a  point  where  it 
crosses  an  inia^rinarv  line  drawn  from  that  tootJi  to  the  anMe 
of  the  jaw.  lie  enters  the  }»(jint  of  the  knife  nearly  three- 
quarters  of  an  inch  hehind  and  below  the  tooth,  presses  it 
down  to  the  bone  and  cuts  toward  the  tooth.  This  neces- 
sarily divides  the  nerve.  The  projection  of  the  alveolar 
ridge  might  protect  the  nerve  from  a  straight  bistoury,  and 
therefore  a  curved  one  should  be  used. 


FACIAL  NERVE. 

This  nerve  has  occasionally  been  stretched  and  crushed 
for  the  relief  of  clonic  spasms  of  the  corresponding  muscles. 
A  semi-lunar  incision  is  made  around  the  lower  attachment 
of  the  ear  with  a  short  liberating  incision  downward  from  its 
centre ;  the  Haps  are  dissected  back,  and  the  nerve  exposed 
by  drawing  the  parotid  downward,  forward  and  outward. 


TENOTOMY. 

Professor  Sayre,^  in  answering  the  question.  How  arc  we 
to  determine  whether,  in  any  given  case,  we  shall  be  com- 
pelled to  resort  to  tenotomy?  lays  down  the  following  rule 
as  of  universal  application  : 

"Place  the  part  contracted  as  nearly  as  possible  in  its 
normal  position,  by  means  of  manual  tension  gradually  ap- 
plied, and  then  carefully  retain  it  in  that  position;  while 
the  parts  are  thus  placed  upon  the  stretch,  make  additional 
point-pressure  with  the  end  of  the  finger  upon  the  parts 
thus  rendered  tense,  and  if  such  additional  pressure  pro- 
duces reflex  contractions,  that  tendon,  fascia,  or  muscle 
must  be  divided,  and  the  point  at  which  the  reflex  spasm  is 
excited  (the  point  at  which  the  pressure  is  applied)  is  the 
point  where  the  operation  should  be  performed." 

According  to  Prof.  Sayre,  the  blade  of  a  tenotomy  knife 
should  be  one  inch  long,  its  shank  one  and  three-quarters, 
its  handle  strong  and  marked  in  such  a  way  that  the  sur- 

^  Orthojiedic  Surgery  and  Diseases  of  the  Joints,  N.  Y.,  1870,  p.  27. 


220  NEUROTOMY    AND    TENOTOMY. 

geon  can  see  at  a  glance  in  which  direction  the  edge  of  the 
blade  is  turned.  The  blade  may  be  straight  or  curved,  it 
should  be  thick  at  the  heel,  very  narrow,  and  the  point 
should  be  somewhat  rounded  and  sharpened  from  side  to 
side  like  a  wedge  or  chisel. 

A  fold  of  skin  should  be  pinched  up  at  the  side  of  the 
tendon,  and  the  knife  entered  at  its  base,  so  that  a  continu- 
ous track  will  not  be  left  on  its  withdrawal.  A  preliminary 
puncture  may  be  made  with  a  sharp-pointed  knife  or  lancet 
to  facilitate  the  entry  of  the  tentome. 

The  knife  must  be  entered  ''on  the  flat"  and  passed  either 
under  the  tendon  or  between  it  and  the  skin  ;  its  edge  is 
then  turned  toward  the  tendon  and  the  division  effected 
with  gentle  sawing  movements,  the  thumb  being  pressed 
firmly  against  the  tendon  if  the  knife  has  been  passed 
under  it. 

Durino-  the  entrv  of  the  knife  and  the  division  of  the 
tendon,  the  latter  must  be  kept  firmly  upon  the  stretch,  and 
as  soon  as  the  division  is  complete  the  knife  must  be  turned 
upon  its  side  and  withdrawn,  while  the  surgeon  follows  its 
point  with  his  thumb  or  finger  so  as  to  force  out  any  blood 
that  may  be  in  its  track  and  to  prevent  the  entrance  of  air. 

Seal  the  wound  with  plaster  or  collodion,  and  then  bring 
the  member  into  the  desired  position. 

Tendo  Achillis. — The  knife  should  be  entered  on  the 
inner  side  of  the  tendon  near  its  border,  about  one  inch 
above  the  upper  surface  of  the  calcaneum.  In  this  way  the 
posterior  tibial  artery,  which  lies  between  the  tendon  and 
the  inner  malleolus  and  below  the  deep  fascia,  is  secured 
from  injury.  The  heel  must  be  depressed  as  much  as  pos- 
sible, so  as  to  make  the  tendon  more  prominent,  and  give 
additional  security  to  the  artery. 

TibiaJis  Posticus. — The  tendon  of  this  muscle  may  be 
divided  (A)  above  the  malleolus,  or  (B)  on  the  side  of  the 
foot  just  behind  its  insertion  into  the  scaphoid. 

A.  Above  the  3IaUeohis. — The  muscle  is  made  tense  by 
everting  the  foot :  the  knife  is  entered  at  the  inner  side  of 
the  tendon  and  passed  behind  it. 


TENOTOMY.  221 

B.  On  thr  Sid<-  of  fh<-  Foot. — Same  ])<»sition  ^ivon  to  tlic 
foot.  TIr'  knife  slioiild  Itc  directCMl  fioiii  altovc  dowinvard, 
and  ])assed  under  the  upper  border  of  the  tendon  at  a  j)oint 
lialf  an  ineh  beh»w  and  in  front  of  the  tip  of  the  malleolus. 
Bell^  prefers  to  cut  toward  the  bone. 

TUnalis  Anticus. — Can  be  easily  made  prominent  and 
isolated. 

Peromi. — May  be  divided  at  the  posterior  face  of  the 
lower  end  of  tlie  fibula,  or  on  the  side  of  the  foot  below  and 
in  front  of  the  tip  of  tlie  outer  malleolus. 

Flexor  Tendons  at  the  Knees. — It  must  be  remembered 
that  the  external  popliteal  nerve  accompanies  the  tendon  of 
the  biceps  closely,  lying  upon  its  inner  side. 

Sterno-cleido-mastoid. — The  danger  to  be  avoided  in  this 
operation  is  that  of  injury  to  the  external  jugular  vein  at 
the  outer  border  of  the  muscle,  or  to  the  anterior  jugular 
vein  at  its  inner  border.  The  first  can  usually  be  seen 
under  the  skin  and  avoided,  the  other  leaves  the  muscle 
about  three-quarters  of  an  inch  above  the  sternum  and  passes 
backward.  The  muscle  should  be  divided  about  half  an 
inch  above  the  top  of  the  sternum,  and  most  authorities 
agree  in  preferring  to  divide  from  before  backward.  The 
knife  should  be  entered  at  the  outer  border  of  the  muscle. 

Levator  Palpehrce. — In  a  case  of  paralysis  of  the  orbi- 
cularis palpebrarum  followed  by  retraction  of  the  levator 
palpebrae  with  inability  to  close  the  eye,  and  subsequent 
ulceration  of  the  cornea.  Professor  Detmold  divided  the 
latter  muscle  at  its  attachment  to  the  upper  edge  of  the  tar- 
sal cartilage.     The  result  was  very  good. 

1  Manual  of  Surgical  Operations,  3cl  edition,  p.  288. 


19* 


PART    \1. 

PLASTIC  OPERATIONS  ON  THE  FACE. 

Plastic  operations  are  recjuired  for  the  relief  of  congeni- 
tal defects,  or  for  the  restoration  of  parts  lost  by  disease  or 
injury.  The  methods  most  commonly  employed  are  of  two 
kinds : 

1.  Bi/  Approximation  of  the  Edges. — This  is  applicable 
to  cases  in  which  the  loss  of  tissue  is  not  great,  and  the  ad- 
joining parts  are  supple.  The  edges  of  the  gap  are  simply 
pared  and  brought  together.  It  is  sometimes  necessary  to 
make  ''liberating  incisions"  on  one  or  both  sides  for  the 
relief  of  tension. 

2.  By  Transfer  of  a  Flap. — A  flap  of  suitable  shape 
and  size  is  dissected  up  and  transferred,  by  turning  it  about 
its  base,  to  the  place  where  it  is  needed,  its  vitality  being 
insured  by  the  preservation  of  its  base  or  pedicle.  This 
method  admits  of  a  great  variety  of  modifications  in  its  de- 
tails, from  a  simple  sliding  of  a  skin-flap,  which  difi'ers  but 
slightly  from  the  method  by  approximation,  to  the  transfer 
of  skin,  muscle,  and  bone  or  the  taking  of  the  flap  from  an- 
other limb  or  individual. 

The  names  Indian.  Italian.  French^  and  G-ennan  methods 
have  been  given  to  the  difi'erent  varieties,  but  YerneuiP  has 
pointed  out  the  impropriety  of  continuing  to  employ  them, 
especially  since  at  least  two  of  them,  the  French  and  G-er- 
man,  have  their  origin  in  an  over-sensitive  patriotism,  not 
mindful  enough  of  the  actual  facts.  The  Indian  and  Italian 
methods  were  first  employed  for  the  restoration  of  the  nose ; 
in  the  former,  a  flap  was  taken  fi^om  the  forehead  and  brought 
down  by  twisting  the  pedicle  which  occupied  the  space  be- 
tween the  eyebrows.  The  term  is  now  applied  to  any  ope- 
ration in  which  the  flap  is  made  with  a  long  pedicle  situated 
at  some  distance  from  the  space  which  the  flap  is  to  cover, 

^  Memoires  de  Chirurgie,  vol.  i.     Chirurgie  Reparatrice,  p.  401. 


I'LASTIC    OPERATIONS    ON    TIIK     P'A(?K.        228 

and  ill  uliich  also  the  flap  is  ])roii<^lit  into  place  by  rotation 
over  a  greater  or  less  arc  described  alxmt  I  be  baso  of  tlic 
pedicle  as  a  centre  (see  Fi^.  127). 

In  the  Italian  inethod  the  flap  is  taken  from  a  distant 
part  of  the  body,  as  in  restoration  of  the  nose  by  a  Hap 
taken  from  the  arm  (Fig.  129).  Ta<^lia('ozzi,  of  Bolo^^na, 
the  originator  of  this  method,  allowed  the  Hap  to  sui)pinate 
for  a  few  days,  so  as  to  increase  its  thickness,  before  fas- 
tening it  in  its  new  situaiion.  Graefe  sought  for  primary 
union,  and  gave,  rather  pompously,  the  name  G^Tmau  method 
to  this  modilication,  ignorant  of  the  fact  that  it  had  been  sug- 
gested more  than  a  ccHtury  before  by  Keneaulme  de  la 
Garanne,  and  unmindful  of  the  other  fact  that  it  contained 
no  new  princii)le,  and  must  have  been  entertained  by  Tag- 
liacozzi,  and  only  rejected  for  the  sake  of  another  advantage 
incompatible  with  it. 

In  the  so-called  French  method,  the  principles  of  which 
are  found  in  C^elsus,  the  flap  has  a  broad  base,  and  is  brought 
into  place,  not  by  rotation,  but  by  traction  in  the  direction 
of  its  axis  (Figs.  110  and  122).  The  variations  and  com- 
binations of  these  methods  are  now  so  numerous,  that  the 
names  no  longer  have  much  descriptive  value. 

General  Principles. — The  edges  of  the  flaps  must  be 
brought  together  without  tension,  and  united  very  accurately 
by  means  of  fine  silk,  catgut,  or  silver  sutures  ;  and  it  is  well 
to  cut  the  edges  obliquely  so  as  to  have  a  broader  surface  of 
contact  as  proposed,  I  believe,  by  Dr.  Packard. 

All  hemorrhage  must  cease  before  the  flaps  are  brought 
into  place.  The  presence  of  a  clot  of  blood  under  a  trans- 
ferred flap  is  one  of  the  most  common  causes  of  failure. 

Flaps  must  be  taken  from  healthy  non-cicatricial  skin, 
and  whenever  the  skin  is  thin  and  not  very  vascular,  the 
subcutaneous  layer  should  be  taken  with  it  to  insure  its 
vitality. 

The  base  of  a  flap  should  occupy  the  quarter  from  which 
the  main  supply  of  blood  is  received,  and  the  direction  and 
shape  of  the  flap  should  be  such  that  it  can  be  brought  into 
place  with  the  least  amount  of  twisting  of  the  base. 

The  flap  should  be  made  considerably  larger  tlian  the 
space  it  is  to  fill,  and,  to  insure  accuracy,  it  is  well  to  cut 


224 


PLASTIC    OPERATIONS    ON    THE    FACE. 


it  according  to  a  pattern  previously  made  of  paper  or  oil 
silk.  It  is  well  also  to  mark  the  angles  by  fine  pins  planted 
erect  in  tlie  skin. 

The  raw  surface  left  by  the  dissection  of  a  flap  may  be 
partly  covered  by  drawing  its  edges  together  with  sutures; 
the  remainder  must  be  left  to  granulate.  Dr.  Gurdon  Buck^ 
recommended  a  dressing  for  it  which  he  calls  the  ''  collodion 
crust;"  it  is  made  by  covering  the  surface  with  dry  scraped 
lint,  and  then  with  an  additional  layer  of  lint  saturated  with 
collodion. 

The  antiseptic  method  should  be  employed,  as  far  as  pos- 
sible, to  prevent  or  diminish  suppuration,  and  thereby  restrict 
the  formation  of  cicatricial  tissue.     With  its  aid  greater  ten- 
sion can  be  made  with  the 
i'lG-  ^'9-  sutures   than  would  other- 

wise be  safe,  and  the  chance 
of  the  occurrence  of  erysi- 
pelas becomes  less. 


CHEILOPLASTY. 

A.  Lower  Lip. — Resto- 
ration of  the  lower  lip  is 
usually  undertaken  to  make 
good  the  loss  of  substance 
occasioned  by  the  removal 
of  an  epithelial  tumor.  The 
choice  of  a  method  depends 
upon  the  extent  of  the  dis- 
ease. 

1.  \'Lncision  (Fig.  99). 
— When  the  tumor  is  small, 
involving  not  more  than  one- 
quarter  or  one-third  of  the  lip,  it  may  be  removed  by  a 
V-incision,  and  the  sides  of  the  gap  brought  together  with 
one  or  two  points  of  twisted  suture.  The  mucous  membrane 
on  the  inside  of  the  lip  should  Ijc  excised  to  the  same  extent 
as  the  skin,  although  it  is  not  usually  involved  in  the  disease. 


( 'hciloplasK,  v-incision. 


*  Reparative  Surgery,  1876,  p   13. 


CH EI LO PLASTY 


225 


If  not   rcinovcMl   it  (onus  a  (lisagrcea])lc   foM   <>r  pucker    in 
the  lip. 

The  harelip  pins  must  be  deeply  })liice(l,  passing  close  to 
the  mucous  membrjme  on  tlie  inside.  Tliis  insures  confron- 
tation of  the  raAV  surfaces  throughout  their  entii'e  l)readth, 
and  the  pressure  of  the  twisted  sutures  prevents  hemorrhage. 

Fio.  100. 


Oval  liori/.onhil  iiicisiun. 

2.  Oval  Horizontal  Incismi  (Fig.  100). — When  the  tumor 
covers  a  considerable  extent  of  surface,  but  does  not  pene- 
trate deeply,  it  may  be  safely  excised  by  cutting  under  it 
with  curved  scissors.  The  mucous  membrane  and  skin  may 
then  be  stitched  together,  or  the  wound  allowed  to  heal  by 
granulation. 


Fig.  101. 


Fig.  102. 


Cheiloplasty,  Celsus's  incisions. 


('heiloi)lasty,  C'elsus's  flaps  in  plac( 


3.  3fethod  of  Orlsusor  Serves  (Figs.  101  and  102).— The 
Y-incision  is  supplemented  by  a  horizontal  one  on  each  side 
carried  outward  from  tJie  angle  of  the  mouth  for  about  two 
inches,  and  comprising  the  whole  thickness  of  the  cheek  for 


226 


PLASTIC    OPEKWTIONS    ON    THE    FACE. 


tlie  first  two-tliirds  of  its  length,  lout  dividing  tlie  mucous 
membrane  at  a  somewhat  hiHier  level  than  the  skin.  The 
lower  ffino'ivo-labial  fold  is  divided  close  to  the  a;um  on  both 
sides,  and  the  dissection  carried  downward  close  to  the  peri- 
osteum, and  backward  toward  the  angle  of  the  jaw  until  the 
edges  of  the  gap  in  the  lip  can  be  brought  together  without 
tension.  The  sides  of  the  Y  are  then  brought  togetlier,  and 
the  lip  formed  from  the  lower  parts  of  the  horizontal  incisions 
(Fig.  102).  The  mucous  membrane  and  skin  are  stitched 
toi^ether  alonsx  the  ediic  of  the  new  lip.  and  the  remainino; 

portion  of  the  lower  flap  on 
^^^-  100.  each  side  (that  which  remains 

external  to  the  new  angle  of 
the  mouth)  is  reunited  to  the 
upper  flap.  The  mucous  mem- 
brane at  the  outer  end  of  the 
horizontal  incision  is  stitched 
to  the  skin  and  covers  the 
angle. 

4.  Dieffeyihach  (Fig.  103) 
adds  a  vertical  incision  at  the 
end  of  each  horizontal  one, 
thus  marking  out  two  quadri- 
lateral flaps  which  are  brought  together  in  the  median  line. 
The  gaps  left  in  the  cheek  by  the  transfer  are  allowed  to 
close  by  granulation. 


Cheiloplasty,  Diefifcubach's  method. 


Fig.  104. 


Fig.  105. 


Syme-Buclianan  incisions. 


Syme-Buchanan  flaps  in  place. 


5.  Synu'-Bw'lianan  (Figs.  104  and  105). — The  method 
])y  latero-inferior  flaps  is  ascribed  by  some  to  Syme,  by 
others  to  Buchanan,  of  Glasgow. 


CHEILOTLASTY 


227 


After  llic  tumor  li;is  been  removed  Ity  llie  usiimI  V-iiK'isioii, 
the  iiK'isioiis  are  })rol()i);^e<l  downward  and  outward  lur  nearly 
an  ineli,  and  tlien  curved  upward  and  outward.  These 
ihaps  are  dissected  oft'  the  bone  and  brought  together  in  the 
median  line.  The  mucous  membi-ane  and  skin  are  stitched 
together  along  the  upper  edge,  the  gaps  left  below  by  the 
shifting  of  the  Ihips  dniwn  together  as  much  as  possible,  and 
the  remainder  left  to  heal  by  granulation. 

Ilanh'  and  Trelat  (Figs.  lUU  and  107)  make  the  flap  on 


Fia.  10(5. 


Fia.  107. 


-^v^^^ 


one  side  longer  and  lift  it  over  the  other  to  form  the  new  lip 
the  shorter  flap  being  used  as  a  support  for  the  former. 

6.  Buck's  Method  (Figs.  108  and  109).— l^uck  preferred 
to  make  two  operations.  He  first  removed  the  tumor  by 
the  V-incision,  brought  the  sides  of  the  gap  together,  and 
allowed  them  to  unite.  After  the  union  had  become  com- 
plete he  restored  the  angle  of  the  mouth  and  lengthened  the 
lower  lip  with  material  taken  from  the  upper  one  by  the 
following  method.^ 

In  Fig.  108,  B  B  represent  two  pins  inserted  a  finger's 
breadth  below  the  under  lip  border,  one  on  either  side  of 
the  chin,  a  little  to  the  outside  of  the  angle  of  the  mouth, 
and  equidistant  from  the  median  line;  I)  I)  nve  also  two 
pins  inserted,  one  on  either  side,  into  the  upper  lip  at  the 


'  Reparative  Surgery,  1870,  p.  22  et  seq. 


228        PLASTIC    OPERATIOMS    ON    THE    FACE. 

margin  of  the  vermilion  border,  equidistant  from  the  median 
line,  and  at  such  distance  apart  as  to  include  between  them 
sufficient  length  of  lip  border  for  a  new  upper  lip.     The 

Pig.  108. 


Restoration  of  lower  liji.     Buck's  incisions. 


Steps  of  the  operation  are  then  the  following :  With  the 
forefinger  of  the  left  hand  placed  on  the  inside  of  the  mouth, 
the  left  cheek  is  to  be  kept  moderately  on  the  stretch  while 
it  is  transfixed  with  a  sharp  knife  at  the  point  B.  An  in- 
cision is  then  carried  throuorh  the  entire  thickness  of  the 


Fig.  109. 


Kestoration  of  lower  lip.     Bucks  flaps  in  i)lace. 

cheek,  upward  and  a  little  outward,  a  distance  of  one  inch 
and  a  half  to  a  point  E.  near  the  middle  of  the  cheek.  The 
corresponding  side  of  the  upper  lip  should  next  be  trans- 


CU EI LOP LA STY 


229 


fixed  at  tlie  point  2),  and  tlic  incision  carricMJ  tliroiifrli  tlie 
lip  and  clicck  outward  and  a  litllc  upward  to  join  the  first 
incision  at  E. 

Tlie  next  step  is  to  transfer  the  triangular  patch,  thus 
marked  out,  from  the  cheek  to  the  side  of  the  chin.  For 
this  purpose  an  incision  should  be  made  on  the  side  of  the 
chin  from  B  vertically  downward  to  the  edge  of  the  jaw 
and  to  the  depth  of  the  periosteum.  The  edges  of  this  in- 
cision retracting  wide  apart,  aftord  a  V-shaped  space  for  the 
lodgement  of  the  triangular  patch,  which  is  now  brought 
around  edgewise,  and  adjusted  by  sutures  in  its  new  posi- 
tion (see  Fig.  109).  The  gap  left  in  the  cheek  is  closed 
by  brincrino-  its  edges  too;ether  and  securing:  them  in  contact 
by  sutures.  By  this  adjustment  a  new  and  naturally  shaped 
angle  is  formed  for  the  mouth  at  the  point  D.  The  incisions 
should  be  made  Avith  the  utmost  precision,  and  special  care 
should  be  taken  that  the  lining  mucous  membrane  is  divided 
exactly  to  the  same  extent  as  the  skin. 

The  same  procedure  may  be  applied  to  the  other  side  of 
the  mouth,  and  executed  at  the  same  operation. 

7.  Square  Lateral  Flajys,  Malgaigne  (Fig.  110). — The 
tumor    is    circumscribed   bv  two   vertical    incisions  carried 


Fig.  110. 


Clieiloi)lasty,  Malgaigne. 

downward  from  the  edge  of  the  lip,  and  a  third  horizontal 
one  uniting  the  low^er  ends  of  the  first  two.  To  fill  the 
square  gap  thus  created,  two  horizontal  incisions  are  made 
on  each  side,  one  from  the  angle  of  the  mouth,  the  other 
from  the  lower  corner  of  the  gap.  The  flaps  circumscribed 
by  these  incisions  are  brought  forward  and  united  in  the 

20 


230 


PLASTIC    OPERATIONS    OX    THE    FACE 


median  line,  and  the  mucous  membrane  stitched  to  the  skin 
along  the  edge  of  the  lip  and  at  the  commissures.  (See 
also  8,  Mctliod  of  Cclsus,  p.  225,  and  Stomatoplasty^  v. 
inf.) 

8.  Square  Vertical   Flaps   (Fig.    111). — Sedillot  made 
the  flap  at  right  angles  to  the  line  of  tlie  mouth.     The  in- 


FlG.  111. 


cisions  are  shown  in  Fig.  111.  Each  flap  is  swung  around 
to  meet  the  other  in  the  median  line,  its  inner  vertical  bor- 
der becoming  the  edge  of  the  lip. 

B.  Angle  of  the  Mouth  {Stomatop)lasty). — An  attempt  to 
restore  a  large  portion  of  either  lip  by  means  of  material 
taken  from  the  other,  or  to  close  a  gap  by  simple  approxi- 
mation not  infre(|uentlY  leaves,  the  mouth  small,  rounded, 
and  pouting,  with  obliteration  of  one  or  both  angles.  This 
defect  can  be  overcome  by  the  operation  described  on  page 
227.  as  Buck's  method  of  restoration  of  the  lower  lip,  or 
by  extending  the  mouth  laterally  by  a  horizontal  incision 
involving  both  skin  and  mucous  membrane,  and  then  pre- 
venting reunion  by  stitching  the  skin  and  mucous  membrane 
too:ether  on  both  sides  and  at  the  ande  of  the  incision. 
Sedillot  considers  it  indispensable  to  excise  a  portion  of  the 
skin  so  as  to  have  a  comjiarative  excess  of  mucous  mem- 
brane which  when    stitched  to  the  skin  will  roll  outward 


CHKlLOPhASTY. 


231 


and  form  a  vermilion  border.     Tliis  sim})lcMn('tli<)d  lias  Ix'cn 
modified  bv  Dr.  Buck  as  follows: 

Buck's  Operaiini^  for  Enldnjenicnt  of  the  Moutli  a  ml 
llestoration  of  its  An(/Ie.  (Fig.  112.) — An  incision  is  made 
witb  i^reat  exactness  aloiii>-  the  line  of  the  vermilion  border 
circumscribing  the  circular  half  of  the  mouth,  and  extending 
to  an  equal  distance  on  the  upper  and  lower  lips  (a  to  b). 
This  incision  should  only  divide  the  skin,  without  involving 
the  mucous  membrane.  A  shar})-pointed,  double-edged 
knife  should  then  be  inserted  at  the  middle  of  this  curved 
incision,  and  directed  flatwise  toward  the  cheek,  between 
the  skin  and  mucous  membrane,  so  as  to  separate  them 
from  each  other  as  far  as  the  new  angle  of  the  mouth  re- 


FiG.  112. 


Lengthening  of  the  month,  Buck. 

quires  to  be  extended.  The  skin  alone  is  next  divided  from 
the  commissure  of  the  mouth  outward  toward  the  cheek. 
The  underlying  mucous  membrane  is  then  divided  in  the 
same  line,  but  not  so  far  outward.  The  angles  at  the  outer 
ends  of  the  two  incisions  are  then  accurately  united  by  a 
sinojle  thread  suture.  The  fresh-cut  ed<2;es  of  skin  and 
mucous  membrane  above  and  below,  that  are  to  form  the 
new  lip  borders,  are  shaped  by  paring   first  the  skin   and 

1  Reparative  Surgery,  p.  *J8,  et  seq. 


232        PLASTIC    OPERATIONS    ON"    THE    FACE. 

then  the  mucous  membrane  in  such  a  manner  that  the  hitter 
shall  overlap  the  former,  after  they  have  been  secured 
together  hj  fine  thread  sutures  inserted  at  short  intervals. 

C.  Upper  Lip. — The  V-incision  and  the  oval  horizontal 
incision  (p.  225)  may  be  used  when  the  loss  of  tissue  will 
be  small.  Also  the  square  lateral  flaps  (p.  229)  when  the 
gap  to  be  filled  is  in  the  centre  of  the  lip  and  rather  large. 

1.  Vertical  Flaps  (Figs.  113  and  114).— These  maj-  be 
made  with  the  base  directed  upward  (Sedillot),  or  down- 
ward (Chauvel).     Chauvel  claims  that  the  latter  method  is 


Fig.  1L3. 


Fig.  114. 


Cheiloplasty  of  tipper  lip.     Sediilot. 


Sedillot     Flaps  in  place. 


to  be  preferred  because  the  retraction  of  the  cicatrix  in  the 
former  tends  to  draw  the  new  lip  upward  and  expose  the  teeth. 

The  flaps  comj^rise  the  entire  thickness  of  the  cheek,  are 
turned  inward  at  right  angles  to  their  former  position  and 
united  in  the  median  line.  The  gaps  left  in  the  cheek  by 
their  removal  are  brouojht  toojether  with  sutures  or  left  to 
ixranulate. 

2.  Infero-lateral  Flap  (Buck).  Fig.  115. — For  loss  of 
the  right  half  of  the  upper  lip  Dr.  Buck  employed  the  fol- 
lowins:  method,  enlarorinc'  the  mouth  afterward  and  reestab- 
lishing  the  angle  by  tlie  inethod  described  above  (p.  231). 

The  extremity  of  the  under  lip,  where  it  joined  the  right 
cheek,  was    divided  throucrh   its    entire  thickness  at  rio-ht 


CHEILOJ'LASTY. 


283 


angles  to  its  border,  and  tlie  division  eaiiied  to  tlie  extent 
of  one  ineli  from  tlie  border  (a  to  ^s  Fig.  lir>).  A  second 
incision  was  made  from  tlie  terminus  of  the  first  parallel  to 
the  lip  border  for  a  distance  of  one  inch  and  a  half  toward 
the  chin,  b  to  c.  The  rpiadrilateral  flap  thus  formed  from 
the  under  li})  was  folded  edgewise  upon  itself,  and  made  to 
meet  the  remaining  half  of  the  up})er  li}),  ;ind  l)e  adjusted  to 
it  by  its  free  extremity.  In  order,  however,  to  make  this 
fold,  the  under  lip  had  first  to  be  divided  obliipiely  half 
across  its  base,  c  to  d. 

Fig.  115. 


Repair  of  upper  lip  by  infero-lateral  flap.     Buck. 


The  left  half  of  the  upper  lip  was  prepared  for  the  new 
adjustment  hj  dividing  the  buccal  mucous  membrane  close 
to  the  jaw  and  detaching  the  parts  above  toward  the  orbit 
from  the  underlying  periosteum,  and  secondly  by  paring  a 
strip  of  vermilion  border  from  the  extremity  of  the  half-lip 
of  sufficient  length  to  permit  the  end  of  the  half-lip  to  be 
matched  to  the  free  extremity  of  the  under-lip  flap.  The 
parts  concerned  having  been  thus  jirepared,  the  under-lip 
flap  was  doubled  edgewise  upon  itself,  and  its  free  extre- 
mity adjusted  to  the  half  of  the  upper  lip,  and  the  two 
secured  to  each  other  in  a  vertical  line  below  the  columna 
nasi  by  sutures.     The  space  between   the   newly  adjusted 

20* 


234 


PLASTIC  OPERATIONS  OX  THE  FACE 


half  of  the  mouth  and  the  neighboring  cheek  was  closed  by 
approximating  the  opposite  parts  and  securing  them  to  each 
otlier  by  sutures  after  their  edges  had  been  carefully 
matched.     (Fig.  112  .•<hows  the  result  of  this  operation.) 


HARELIP. 


If  the  patient  is  a  young  child  its  arms  should  be  securely 
bound  to  its  sides  with  a  towel,  and  its  head  firmly  held  by 
an  assistant.  After  anaesthesia  has  been  obtained  it  can 
be  easily  kept  up  by  applying  to  the  nostrils  from  time  to 
time  sponges  saturated  with  ether. 

Single  Harelip^  Simple. — The  simplest  method  of  ope- 
rating is  to  pare  the  sides  of  the  cleft  and  bring  the  raw 
surfices  together  by  a  few  sutures.  The  objection  to  the 
method  is  that  the  retraction  of  the  scar  produces  a  more 
or  less  considerable  depression  in  the  free  border  of  the  lip. 
It  has  therefore  been  generally  abandoned  for  one  of  the 
following. 

1.  Douhle  Flaps  (Fig.  116). — In  order  to  hold  the  parts 
upon  the  stretch  and  insure  precision  in  making  the  cuts,  a 

Fig.  116. 


Sini)ilc  .single  liarelip,  double  flaps.  A  Incisions.  B.  Flaps  turned  down.  C.  Liga- 
ture for  holding  lip  tense  D  Incisions  to  shorten  and  adju.-t  flaps  E  Threail  liassed 
through  the  ends  of  the  flaps. 

stout  ligature  should  be  passed  through  the  lip  at  each 
angle  of  the  cleft,  or  each  angle  should  be  seized  with  artery 
forceps.  The  lip  being  drawn  forward  and  downward  by 
means  of  the  ligature  or  forceps,  the  mucous  membrane  is 


HARELIP.  235 

(lividiMl  close  to  the  gum  and  the  dissection  carried  upward 
and  hackwanl  as  far  as  may  ho  necessary  to  allow  the  sides 
of  the  clefl  to  be  brouirlit  to;:etlier  without  tension. 

Then  making  one  side  of  the  cleft  tense,  by  drawing  upon 
its  ligature,  the  lip  is  transfixed  near  the  angle,  and  the 
incision  carried  upward  along  the  border  of  the  cleft  to  its 
top,  or,  if  necessary,  into  the  nostril,  thus  cutting  out  a 
narrow  flaj>  which  remains  attached  at  its  lower  extremity 
to  the  lip  (Fig.  IIG,  A).  A  similar  flap  is  then  made  ui)on 
the  other  side,  the  two  are  turned  down,  so  that  their  raw- 
surfaces  face  each  other,  and  a  thread  passed  through  their 
free  ends  (Fig.  116,  JE).' 

The  freshened  edges  of  the  cleft  are  then  confi'onted,  a 
harelip  pin  jtlaced  near  the  vermilion  border  and  another 
near  the  nostril,  and  two  or  three  fine  silk  or  silver  sutures 
inserted  between  them.  The  ends  of  the  dependent  flaps 
are  then  cut  ofi"  obli(iuely,  enough  being  left  to  form  a  dis- 
tinct projection  on  the  lip  after  they  have  been  unite<l  with 
fine  sutures.  By  this  means  the  formation  of  a  notch  by 
the  retraction  of  the  cicatrix  is  avoided. 

2.  When  the  cleft  was  shallow,  Nelaton  left  the  flaps 
attached  to  each  other  at  the  apex,  turned  them  down,  and 

Fig.  117. 


Harelip,  Nelaton's  methol.     A.  Incision.     B.  Flap  turned  down. 

brought  the  raw  surfaces  together  as  above  described  (Fig. 
117). 

3.  Single  Flap  (Fig.  118). — A  flap  is  made  upon  one 
side  only,  usually  the  shorter  portion  of  the  lip.  The  oppo- 
site side  of  the  cleft,  and  a  portion  of  the  fi-ee  border  of  the 
lip  adjoining  it,  are  freshened  by  the  removal  of  a  strip  of 
skin  and  mucous  membrane.  The  sides  of  the  cleft  are 
approximated,  and  the  flap  applied  to  the  fi*ee  border  of 
the  lip. 


236        PLASTIC    OPERATIONS    ON    THE    FACE. 

4.  Giraldess  3IetJiod  (Fig.  119). — This  is  applicable 
only  when  the  cleft  extends  into  the  nostril.  The  flap  on 
the  short  side  is  made,  as  before  described,  with  its  base 

Fig.  118. 


Harelip.    Single  flap. 

below ;  that  on  the  long  side  is  reversed,  being  left  attached 
at  its  upper  end.  A  third,  horizontal  incision  is  carried 
outward  from  the  edge  of  the  nostril,  at  the  point  of  the 
first  flap,  to  make  that  portion  of  the  lip  more  movable. 
The  second  flap  is  then  turned  upward  across  the  nostril, 
the  first  brought  down  to  take  its  place,  and  the  two  raw 


Fig.  119. 


Harelip.    Giraldes's  method. 


surfaces  thus  brought  into  contact  united  by  sutures.  The 
long  side  of  the  lip  may  also  be  mobilized,  if  desirable,  by  a 
horizontal  incision  running  from  the  gap  close  below  the 
columna  and  the  corresponding  nostril. 

Double  Harelip,  Simple  (Fig.  120). — Flaps  are  made 
upon  the  lateral  portions,  A  and  B,  as  before  described  (p. 
234,  1),  and  the  sides  of  the  central  portion,  (7,  are  pared. 
The  flaps  are  then  brought  together,  as  shown  in  the  figure, 
after  mobilizing  the  lip  by  free  division  of  the  gingivo-labial 
fold  and  carrying  the  dissection  Avell  upward  and  outward. 


HAKELir. 


237 


pins  passed  to  include  the  sides  and  the  central  portion  at 
the  base  nnd  apex  of  the  latter,  the  flaps  trimmed  (p.  -•>•'>), 
and  united  witli  fine  sutures. 

If  the   })arts  arc  too  scanty  to  permit   the  use  of   this 


Fig.  liU 


Double  harelip. 

method,  liberating  incisions  must  be  made  around  the  alge 
nasi,  or  flaps  obtained  from  the  cheek.  (See  Upper  Lip, 
p.  282,  et  seq.) 

Complicated  RareJip. — Harelip  may  be  complicated  by 
fissure  of  the  palate  and  alveolar  process.  When  the  fissure 
is  single  the  bone  on  the  long  side  of  the  lip  projects  beyond 
its  proper  line.  In  very  young  children,  it  may  sometimes 
be  forced  back  into  place  by  making  pressure  upon  it  with 
the  thumb,  but  it  is  easier  to  fracture  it  first  with  Butcher's 
pliers ;  the  bent  blade  of  this  instrument  being  applied  upon 
the  anterior  surface  near  the  further  nostril.  The  two  por- 
tions of  the  alveolar  arch  soon  unite  after  they  have  been 
brought  into  contact,  especially  if  the  opposing  surfaces 
have  been  pared.     Sutures  are  not  needed. 

When  there  is  double  fissure,  the  intermediate  portion  of 
bone  containing  the  incisor  teeth  projects  so  far  that  it 
seems  to  be  an  appendage  of  the  nose  rather  than  of  the 
mouth.  In  order  to  restore  it  to  its  place,  it  is  necessaiy 
to  divide  the  vomer  with  strong  scissors,  or,  better,  to  cut  a 
triangular  piece  out  of  the  septum  of  the  nose.  It  is  not 
necessary  to  fasten  the  bones  together  with  sutures.  The 
portion  of  skin  covering  the  projecting  bone  must  be  dis- 
secte<l  off,  and  used  to  lengthen  the  columna  nasi  or  fill  out 
the  lip. 

In  extreme  cases  it  may  be  proper  to  cut  away  the  pro- 
jection entirely;  but  whenever  it  can  be  saved  and  brought 


238        PLASTIC    OPERATIONS    ON    THE    FACE. 

into  line,  it  renders  valuable  service  by  giving  the  upper  jaw 
its  proper  length,  and  furnishing  a  space  into  which  artificial 
teeth  can  be  fitted.  The  three  or  four  teeth  which  are  found 
in  this  piece  are  always  so  defective  and  irregularly  placed 
that  they  have  to  be  drawn. 

Fig.  121. 


Cheek  compressor. 


It  is  sometimes  desirable  to  take  the  strain  off  the  sutures 
hy  means  of  a  cheek  compressor,  similar  to  that  represented 


in  Fig.  121. 


For  uranoplasty,  etc.,  see  Operations  upon  the  Mouth. 


RHINOPLASTY. 

The  different  kinds  of  rhinoplastic  operations  may  be 
classified  according  to  the  nature  and  extent  of  the  loss 
which  they  are  designed  to  repair :  1st.  A  snperficial  loss 
not  involving  the  bones  or  septum.  2d.  Loss  of  the  septum 
and  nasal  bones,  the  skin  remaining  entire.  3d.  Loss  of 
more  or  less  of  the  surface  and  septum. 

As  the  loss  of  tissue  is  always  the  result  of  injury  or  dis- 
ease, it  presents  so  many  variations  in  form  and  extent,  that 
it  is  difficult  in  practice  to  determine  the  exact  boundaries 
between  the  classes,  and  this  classification  is  chosen  for  con- 
venience of  description,  and  not  with  the  intention  of  limit- 
ing the  choice  of  an  operation  in  any  given  case  to  those 
described  in  the  class  to  which  the  lesion  might  belong.  For 
the  same  reason,  a  description  of  an  operation  as  actually 


RHINOPLASTY.  239 

pcrfbrnu'd   \\\\\    sniuctiiiios    ])v    more    sorvict'ahlt'    tli.iii    :niv 
general  rules  that  luiL^it  Ke  laid  down. 

As  may  be  readily  understood,  tlie  e\isteiu-e  or  non- 
existence of  the  septum  and  nasal  bones  aftects  materiallv, 
not  only  the  method  of  operatinir.  but  also  the  result.  If 
unsuj)porte(l  centrally,  the  new  member  tends  constantly  to 
shrink  and  ilatten,  and  the  surgeon  has  the  mortification  ()f 
seeing  that  he  has  merely  substituted  one  deformity  for  an- 
other. Oilier  tried  to  meet  this  want  by  including  the  peri- 
osteum in  the  flap  taken  from  the  forehead  by  the  Indian 
method.  There  was,  however,  no  new  formation  of  bone, 
and  the  operation  in  that  respect  was  a  failure.  On  another 
occasion  lie  took  a  strip  of  healthy  periosteum  from  one  of 
the  limbs,  and  tried  to  graft  it  under  the  skin  of  the  fore- 
head, hoping  thereby  to  procure  a  lamella  of  bone,  which 
could  be  used  to  mvc  solidity  to  the  new  nose.  Thinkinir 
the  graft  had  failed,  he  withdrew  the  strip  of  periosteum 
after  a  few  days,  and  then  discovered  that  it  had  united 
nicely  at  one  point.  There  is  reason,  therefore,  to  think 
that  a  more  patient  repetition  of  the  experiment  might  be 
successful.  On  a  third  occasion,  he  included  the  periosteum 
of  the  forehead  in  a  flap  transferred  by  a  modification  of 
the  French  method,  and  by  foldincj  it  together  lonoritudinally 
along  the  centre  he  got  reproduction  of  bone  where  the  two 
layers  faced  each  other. 

1.  Superficial  Defect  not  Invohinci  the  Bones  or  Septum. 
— If  the  loss  of  tissue  is  confined  to  the  integument,  that 
is,  if  the  cartilage  is  spared,  as  it  usually  is  in  cases  of  epi- 
thelioma, no  plastic  operation  should  be  undertaken.  The 
tumor  must  be  carefully  dissected  ofi",  and  the  wound  left  to 
ojranulate.  The  slio^ht  mobility  of  the  inteorument  of  the 
region  prevents  deformity  by  cicatricial  retraction,  and  the 
wound  heals  over,  leaving  a  scar  which  does  not  contrast 
oflensively  with  the  neiirhborino;  skin. 

If,  on  the  other  hand,  there  is  a  gap  to  be  filled,  one  that 
is  small  and  does  not  involve  the  free  border  of  the  ala, 
square  lateral  flaps  may  be  made  by  horizontal  incisions 
(Fig.  122),  and  drawn  together  after  the}^  have  been  ren- 
dered freely  movable  by  dissection  from  the  underlying  parts. 

If  the  ga])  is  larger,  or  if  one  of  the  ahv  is  lost,  suitalde 


240 


PLASTIC    OPERATIONS    ON    THE    FACE 


oblique  or  vertical  flaps  may  be  taken  from  the  nose  or 
cheek  and  transferred  by  rotation.  Three  of  the  many 
variations  of  this  method  are  shown  in  Figs.  123  and  124. 
Fig.    123,   A,    represents    a  vertical  flap    taken    from    the 


Fig.  122. 


Rhiuoijlasty.     Lateral  flaps. 


cheek  beside  and  below  the  nose,  and  left  adherent  at  its 
upper  end.  The  flap  should  be  cut  long  enough  to  allow  a 
natural  appearance  to  be  given  to  the  free  border  of  the 
ala  by  turning  it  in  upon  itself.     This  device  will  also  pre- 


FiG.  123. 


Fig.  124. 


Ehinoplasty.     A    Single  lateral  flap. 
B    Langenbeck's  uietliod. 


Ttliiuiiplasty.     Deuuuvillier's  method. 


vent  excessive  cicatricial  contraction  of  the  border  and  con- 
sequent narrowing  of  the  nostril. 

Denonvillier  s  Method  (Fig.    124)  sometimes   makes  it 
possible  to  secure  this  object  more  certainly  by  supplying 


KIIIXO  PLASTY.  241 

a  border  that  is  already  cicatrizcil.  Supposing'  the  lower 
portion  of  an  ala  to  be  lost,  a  triangular  Hap,  left  adherent 
to  the  lobe  of  the  nose,  is  marked  out  by  an  incision  which, 
starting  from  a  point  near  the  lobe  on  the  unaftected  side  of 
the  median  line,  is  carried  directly  upward  nearly  to  the 
root  of  the  nose,  and  thence  obliquely  downward  to  the 
upper  outer  c<jrner  of  the  aft*ecte<l  ala.  The  flap  is  mobi- 
lizeil  bv  careful  dissection  off"  the  bone  and  cartilage,  antl 
transferred  downward.  The  gap  left  by  the  transfer  heals 
by  ^granulation.  For  the  sake  of  givini:  more  stiffness  to 
the  border,  Denonvilliei"S  sometimes  includeil  a  strip  of 
cartilage  in  it. 

Von  Ldiu/enbeck^  restored  an  ala  by  taking  a  triangular 
flap  from  the  opposite  side  of  the  nose  (Fig.  123,  B). 
The  flap  was  left  adherent  at  the  apex  of  the  triangle, 
which  lay  near  the  inner  angle  of  the  eye  of  the  aflfecte*! 
side,  while  its  base  occupied  the  opposite  ala.  It  was  dis- 
sected up  carefully  so  as  not  to  include  the  cartilage,  trans- 
ferred to  the  other  side,  and  fasteneil  to  the  fi*eshened 
edges  of  the  gap.  The  wound  left  by  the  removal  of  the 
flap  healeil  by  granulation,  and  so  perfectly  that  it  was 
difficult  to  recoo:nize  there  had  been  anv  loss  of  tissue  at 
that  point. 

Jlichon  restored  the  ala  by  taking  a  triangular  flap  fi*om 
the  septum.  The  base  of  the  flap  was  placetl  anteriorly, 
parallel  to  the  ridge  of  the  nose,  and  the  apex  lay  near  the 
junction  of  the  septum  with  the  floor  of  the  nasal  fossa. 
The  flap  was  dissecteil  up  and  attached  to  the  margin  of  the 
loss  of  substance,  its  mucous  surface  directed  outward,  its 
apex  made  fast  to  the  cheek. 

The  coJumna,  with  or  without  the  tip  of  the  nose,  can 
be  restored  fiom  the  upper  lip.  Dupuytren  and  Dieft'en- 
bach  cut  a  vertical  cutaneous  flap,  adherent  at  its  upper 
end,  immediately  below  the  columna.  turned  it  upward, 
twisting  it  upon  its  pedicle  so  that  its  cutaneous  surface 
remaintni  external,  and  secured  it  in  place.  As  the  twist- 
ing of  the  pedicle  created  considerable  deformity,  Sedillot 
and   Blandin    made    the  flap   of  the  entire  thickness  and 

^  Essais  de  Chirursjie  Plastique  d'apres  les  Preceptes  du  Prof.  B. 
von  Langenbeck,  Bruielles,  1856,  quoted  by  Verneuil. 

21 


242         PLASTIC    OPE  RATIONS    OX    THE    FACE. 

length  of  tliL'  lip.  pared  oft'  its  cutaneous  surface,  and 
turned  it  directly  upward  witli(Ait  twisting  the  pedicle,  the 
mucous  membrane  thus  forming  the  outer  surface.  The 
crap  left  in  the  lip  was  then  closed  with  sutures.  In  Blan- 
din"s  case  the  result  was  excellent,  and  the  mucous  mem- 
brane gradually  assumed  the  characteristics  of  ordinary 
skin  :  but  in  Sedillots  case,  in  which  the  tip  of  the  nose 
had  also  to  be  restored,  the  membrane  remained  red  and 
covered  with  thick  epidermic  scales,  and  the  end  of  the  nose 
looked  much  like  a  cherry.^  In  all  his  rhinoplastic  ope- 
rations Liston  made  the  columna  separately  by  this  method, 
and  found  that  the  mucous  membrane  soon  took  on  the 
appearance  of  ordinary  integument. 

2.  Loss  of  tJie  Septum  and  Nasal  Bo7ies,  the  Skin  re- 
maining entire. — Baron  Larrey,  about  1820,  operated  upon 
a  soldier  the  bridge  of  whose  nose  had  been  shattered  and 
depressed  by  the  explosion  of  a  gun.  He  removed  the 
defoimity  by  dissecting  up  the  adherent  portions  of  skin 
and  replacing  them  in  their  original  position.  The  details 
of  the  operation  are  lacking. 

Dieffenbaeh  published  in  1829  the  description  of  an  ope- 
ration by  which  he  overcame  the  great  deformity  resulting 
from  the  loss  of  the  septum  and  bones  of  the  nose  by  scro- 
fulous disease.  As  the  case  is  a  classical  one,  quoted,  and 
often  very  incorrectly,-  in  the  text-books,  and  is  an  indica- 
tion of  what  may  sometimes  be  accomplished  in  extreme 
cases,  the  following  description  of  it  is  given.^ 

The  patient  was  a  girl  twelve  years  of  age.  She  had 
lost  the  ossa  nasi,  nasal  processes  of  the  ethmoid,  vomer, 
and  cartilages,  and  instead  of  a  prominent  nose  there  was 
a  deep  pit  with  a  ridge  at  the  bottom.  The  plan  of  ope- 
ration was  to  divide  the  remains  of  the  old  sunken  member 

^  Sedillot,  Medecine  Operaloire,  2d  ed.,  vol.  ii.  p.  233. 

2  The  description  in  Holmes's  System  of  Surgery,  vol.  v.  p.  570,  is 
almost  unrecognizable.  It  is  taken  from  Malgaignc's  incorrect  ac- 
count, and  also  contains  at  least  one  gross  error  in  translation. 

'  As  the  original  work  could  not  be  obtained,  this  description  is 
made  up  fnan  an  English  translation  of  the  book,  published  in  1833, 
a  French  translation  uf  the  case  in  the  Gazette  Medicale,  vol.  i.  p. 
65,  1830,  and  a  brief  description  with  plates,  in  a  collection  of  Dief- 
fenbach's  Plastic  Operations,  published  by  two  of  his  pupils  in  1840. 


RHINOPLASTY. 


243 


into  portions,  raise  tliem  np,  and  secure  tlieni  in  tlie  proper 
])osition.  Dieflenbaeh  passed  a  narrow-Maded  knife  first 
into  one  nostril  and  then  into  the  other,  and  cut  out,  makin;^ 
two  incisions,  one  on  each  side  of  the  sunken  ridge  (Fig. 
125,  O).  Tlie  strip  of  skin  between  these  incisions  was  three 
times  as  broad  at  its  Ljwer  end,  where    it  was  connected 


Fig.  12'). 


Dieffenbach's  operation.     B.  The  result.     C.  Tlie  flaps. 

with  the  upper  lip  by  the  shortened  columna,  as  at  its 
upper  part  Avhere  it  joined  the  forehead.  The  cheeks  were 
next  cut  through  down  to  the  bones  on  each  side  by  insert- 
ing the  knife  a  few  lines  below  the  upper  end  of  the  first 
incision  and  carrying  it  obliquely  downward,  parallel  and 
a  little  external  to  the  side  of  the  nose,  and  then  around 
into  tlie  nostril,  thus  separating  the  lateral  attachments  of 
the  alae  nasi.  The  columna  being  too  short,  was  then 
elongated  by  two  slight  incisions  in  the  uj)per  lip,  and  the 
cheeks  rendered  more  movable  by  dividing  their  attach- 
ments to  the  bone  through  the  lateial  incisions.  The  flaps 
were  then  raised,  the  sides  of  the  incisions  pared  oblitfuely 
in  a  manner  to  which   Dieflfenbaeh  attaches  an  im]:ortance 


244        PLASTIC    OPERATIONS    ON    THE    FACE. 

that  seems  undeserved,  reunited,  and  fixed  with  harelip 
pins  and  sutures,  and  the  whole  retained  in  place  by  draw- 
ing the  cheeks  toward  the  median  line  and  fastening  them 
there  with  two  long  pins  passed  under  the  nose  and  through 
the  detached  edges  of  the  cheeks.  This  compression  was 
aided  by  two  splints  of  leather  through  which  the  pins 
passed.  A  quill  covered  with  oiled  lint  w^as  introduced 
into  each  nostril. 

Osteoplastic  Method. — Oilier  treated  successfully  a  some- 
what similar  case  by  making  a  triangular  flap,  its  base 
constituted  by  the  lower  portion  of  the  nose  and  the  ad- 
joining cheeks,  its  apex  situated  x^ne  and  a  half  inches 
above  the  eyebrows.  The  frontal  portion  of  the  flap  in- 
cluded the  underlying  periosteum.  The  left  nasal  bone 
and  vomer  having  been  destroyed  by  the  disease,  central 
support  could  be  obtained  for  the  new  nose  only  by  aid  of 
the  right  nasal  bone,  which  was  accordingly  loosened  with 
a  chisel  and  forced  downward.  The  flap  was  then  trans- 
ferred downward,  pinched  in  laterally  to  increase  its  height 
at  the  bridge,  and  supported  there  by  drawing  the  cheeks, 
previously  loosened  from  their  underlying  attachments, 
toward  the  nose  and  fastening  them  there  with  long  pins.^ 

Double  Layer^  or  Superficial  Flaps  (Fig,  126). — 
Yerneuil"  employed  successfully  a  method  suggested  to  him 
by  Oilier,  in  vJiich  permanent  elevation  of  the  bridge  of 
the  nose  was  secured  by  superposing  two  flaps  and  thereb}^ 
doid^ling  the  thickness.  The  patient  had  discharged  a 
pistol  into  his  mouth,  causing  the  destruction  of  a  portion 
of  the  hard  palate  and  septum,  the  nasal  bones,  part  of  the 
nasal  processes  of  the  superior  maxillary,  the  spine  of  the 
frontal,  and  the  anterior  wall  of  the  frontal  sinuses.  The 
alse  and  lobe  were  uninjured  but  much  flattened:  above 
them  was  a  broad  deep  groove  extending  to  the  middle 
third  of  the  forehead.     The  two  principal  indications  were 

^  For  further  details  of  this  operation  the  reader  is  referred  to  the 
original  account  in  the  Bulletin  de  la  Societe  de  Chirurgie,  1862,  p.  02, 
or  to  its  reproduction  in  Yerreuil's  Chirurgie  Reparatrice,  p.  428,  and 
in  the  Gazette  Hebdomadaire,  1862,  p.  98,  and  also  to  a  similar  ope- 
ration described  more  fully  on  page  249  of  this  manual. 

2  Chirurgie  Pveparatrice,  p.  428,  and  Bull,  de  la  Soc.  de  Chirurgie, 
1862,  p.  70. 


RHINOPLASTY. 


245 


to  briii<r  the  Ijitcral  portions  nearer  the  median  line  and  to 
reconstitute  the  brid^^e  of  the  nose.  The  Litter  couM  be 
permanently  accomplished  only  by  filling  in  the  great  cavity 
which  would  be  left  by  raising  the  sunken  parts. 


Fig.  126. 


Rhiuoplasty,  sunken  nose.     Double  layer,  or  superposed  flaps.     Yerneuil. 

Verneuil  made  an  incision  alono;  the  median  line  of  the 
depression  and  a  transverse  one  at  each  end  of  the  first, 
and  dissected  up  the  two  lateral  flaps  thus  marked  out.  He 
then  raised  an  oblong  flap  from  the  middle  of  the  forehead, 
its  base  remaining  adherent  between  the  eyebrows,  and 
turned  it  directly  downward  so  that  its  raw  surface  was 
directed  outward,  its  tegumentarv  surface  toward  the  nasal 
fossae.  The  two  lateral  flaps  were  then  placed  upon  it  and 
united  in  the  median  line.  The  raw  surfaces  united  with 
each  other,  and  the  result  was  a  nose  elevated  one-third  of 
an  inch  above  the  adjoining  surface. 

Suhcutaneous  3I('thod. — Prof.  Pancoast^  operated  upon 
a  similar  case  in  the  winter  of  1842-3  by  subcutaneous 
division  of  the  adhesions.  The  ossa  nasi  and  septum  had 
been  entirely  destroyed  by  disease,  and  the  nose  was 
sunken  far  below  the  level  of  the  face.  "A  narrow  long- 
bladed  tenotomy  knife  was  introduced  on  either  side  by 
puncture  through  the  skin  over  the  edge  of  the  nasal  pro- 
cess of  the  upper  maxillary  bone.     The  knife  was  pushed 


'  Operative  Surgery,  Phila.,  1852,  p.  858. 
21* 


246        I'LASTIC    OPERATIONS    OX    THE    FACE. 

up  under  the  skin  to  the  top  of  the  nasal  cavity,  and  then 
brou^rht  down,  shaving  the  inside  of  the  bony  wall,  so  as  to 
detach  the  adherent  and  inverted  nose  upon  either  side. 
The  point  of  the  nose  could  now  be  draAvn  out.  .  .  .  The 
nose  still  remained  adherent  to  the  top  of  the  nasal  chasm. 
The  knife  was  a  third  time  introduced  under  the  skin  in  a 
direction  corresponding  nearly  with  the  long  diameter  of 
the  orbits  of  the  eyes  and  the  adhesions  separated  from 
the  nasal  spine  and  internal  angular  processes  of  the  os 
frontis."  The  soft  parts  on  the  cheek  were  loosened  by 
sweeping  the  knife  outward  along  the  surface  of  the  bone  so 
far  as  to  divide  the  infra-orbital  nerve  and  artery  on  each 
side,  drawn  toward  the  median  line,  and  held  together  with 
quilled  sutures  passed  through  the  cavity  of  the  nose. 

In  two  weeks  the  root  of  the  new  nose  had  sunk  to  the 
level  of  the  face,  but  the  patient  was  well  satisfied,  and 
refused  any  further  operation,  beyond  the  removal  of  an 
elliptical  piece  of  skin  to  raise  this  portion  again.  The 
ultimate  result  is  not  known. 

DubrueiP  quotes  a  similar  operation  by  Malgaigne,  but 
without  giving  the  date.  As  it  is  not  mentioned  in  the  lat- 
ter's  Medecine  Operatoire^  edition  of  1837,  it  is  probable 
that  Prof.  Pancoast's  operation  antedates  it. 

3.  Loss  of  more  or  less  of  the  Surfaea  and  the  Septum. 

A.  Indian  Method. — This  method  was  introduced  into 
Europe  in  1814,  by  Carpue,  an  English  surgeon,  and  the 
stimulus  given  by  it  to  this  class  of  operations  was  so  great 
during  the  succeeding  twenty-five  or  thirty  years,  that  this 
period  has  been  called  that  of  the  renaissance  of  rhinoplas- 
tic  surgery.  The  ultimate  results,  however,  were  not  very 
favorable,  and  the  method  has  fallen  into  comparative 
neglect.  It  was  found  that  the  noses,  although  sufficiently 
full,  or  even  excessive  at  the  time  of  the  operation,  under- 
went gradual  atrophy,  and,  when  central  support  was  lack- 
ing, sank  to  the  level  of  the  cheeks.  The  nostrils,  too, 
closed  sometimes  to  such  an  extent,  that  they  would  hardly 
admit  a  probe ;  and,  finally,  the  whole  flap  had  a  tendency 
to  slide  downward,  and  collect  in  a  lump  at  the  end  of  the 

^  Medecine  Operatoire,  p.  451. 


RHINOPLASTY 


247 


nose  after  division  or  excision  of  tlie  pedicle.  The  scar  left 
ui)on  the  forehead  was  a  serious  disii<^urenient,  an<l  the 
attempt  to  diminish  it  by  drawing  the  sides  of  the  gap  to- 
<>"ether  gave  rise  to  complications,  which  endangered  the 
patients  life.  The  operation  itself  was  not  without  dang(3r. 
Dieffenhach  lost  two  out  of  six  patients  upon  whom  he  ope- 
rate* I  in  l*aris. 

The  opc)'((tf07i  was  originally  performed  as  follows  (Fig. 
127) :  A  flap,  the  size  and  shape  of  which  were  determined 
])y  a  pattern  previously  made  of  paper  or  card,  was  marked 
out  ui)on  the  forehead  immediately  above  the  nose.     Care 

Fig.  127. 


Rhinoplasty.     Indian  method  unmodified. 

was  taken  to  make  it  at  least  a  quarter  of  an  inch  broader 
and  half  an  inch  longer  than  the  space  it  was  to  fill.  Its 
base  was  situated  between  the  eyebrow^s,  and  was  half  an 
inch  broad.  At  the  upper  end  of  the  flap  was  a  projecting 
tab  intended  to  form  the  columna.  The  flap,  including  all 
the  tissues  down  to,  but  not  through,  the  periosteum,  was  then 
dissected  up,  brought  down  by  twisting  the  pedicle,  placed 
in  its  new  position  with  its  raw  surface  inward,  and  attached 
by  sutures  to  the  freshened  edges  of  the  gap  it  was  to  fill. 
Prominence  was  given  to  the  ridge  by  stuffing  the  nostrils 
with  plugs  of  oiled  lint,  or  drawing  the  cheeks  toward  the 
median  line  by  means  of  long  pins  passed  transversely 
through  the  edges  and  under  the  nose.     The  gap  in  the 


248        PLASTIC    OPERATIONS    ON    THE    FACE. 

forehead  was  left  to  heal  by  granulation.  After  the  flap 
had  united,  the  pedicle  was  divided,  and  returned  to  its  ori- 
ginal position. 

Modifications} — Larrey  (1820)  pointed  out  the  desira- 
bility of  saving  even  the  smallest  fragments  of  the  original 
nose,  especially  if  they  belonged  to  the  free  border  of  the 
ala.  Prof.  Bouisson"  formulated  this  principle,  and  extended 
it  to  the  other  methods,  as  follows :  1st.  Save  as  much  as 
possible  of  the  septum.  2d.  Give  lateral  support  to  the 
flaps  by  means  of  the  healthy  portion  of  the  cartilage  of  the 
alag.  3d.  Insure  the  regularity  of  the  outline  of  the  nostril 
by  giving  the  lower  border  of  the  flap  cartilaginous  support. 
Dupuytren  and  Dieff"enbach  opposed  the  retraction  and 
closure  of  the  nostrils  by  folding  back  upon  itself  that  por- 
tion of  the  edge  of  the  flap  Avhich  was  to  form  the  free 
border. 

The  torsion  of  the  pedicle  involves  more  or  less  danger 
of  gangrene  by  obstructing  the  return  of  the  venous  blood. 
Lisfranc  (1826)  was  the  first  to  attempt  to  diminish  this 
defect.  By  lengthening  the  incision  on  one  side,  the  base 
or  attachment  of  the  pedicle  was  made  oblique  instead  of 
transverse,  and  the  torsion  correspondingly  diminished  at 
that  point.  Of  course,  the  total  amount  of  torsion  remained 
the  same,  but,  by  being  spread  along  the  pedicle,  it  was 
made  more  spiral  and  less  abrupt.  Von  Langenbeck  (be- 
fore 1856)  went  a  step  further,  and  put  the  base  upon  the 
side  of  the  nose  close  to  the  eye,  the  upper  incision  ending 
at  the  eyebrow,  the  lower  just  below  the  tcndo  oculi.  Lab- 
bat  did  about  the  same  thing  in  1827. 

Auvert,  a  Russian  surgeon  (date  unknown,  but  long  be- 
fore 1850),  made  the  flap  oblique  instead  of  vertical,  still 
keeping  the  base  between  the  eyebrows.  Alquie,  of  Mont- 
pellier  (1850),  proposed  to  make  the  flap  horizontal,  the 
lower  incision  being  hidden  by  the  eyebrow  ;  and  Landreau 
even  curved  it  somewhat  upward  at  the  end,  so  that  the  base 
of  the  pedicle  w^as  hardly  twisted  at  all  in  bringing  down  the 
flap.     Ward   (1854)   made  a  flap  which   was   directed  ob- 

1  The  dates  of  these  modifications,  and  the  award  of  credit  for  their 
suggestion  are  mainly  taken  from  Yerncuil's  C/ur?<?-.(7t'c  Re  par  air  ice,  io 
which  the  reader  is  referred  for  further  details  and  documentary  proof. 

2  Rhinoplastie  lat^rale. 


HH  IN  OP  I.  A  STY.  249 

liqik'ly  Upward,  and  Folliii  (ISoUj  iiiadu  a  Iransvorsf  one; 
in  each  case  tlio  base  of  the  ])edicle  was  upon  or  near  the 
median  line  of  the  forehead,  a  littk'  above  the  eyebrows. 
Uoth  cases  did  well.  The  objection  to  a  ti-ansverse  flap  is 
that  the  retraction  of  the  cicatrix  upon  the  forehead  draws 
the  corresponding  eyebrow  upward.  The  advantages  are 
that  the  torsion  is  less,  and  the  scar  somewhat  disguised  by 
the  natural  lines. 

Various  means  have  been  employed  to  prevent  the  descent 
of  the  flap.  Dieffenbacli  made  a  longitudinal  incision  on  the 
side  of  the  nose,  and  engaged  the  pedicle  in  it,  paring  off 
its  prominences  afterward.  Blandin  excised  the  portion  of 
skin  intermediate  between  the  base  of  the  pedicle  and  the 
loss  of  substance,  and  thus  obtained  a  raw  surface  to  which 
the  whole  length  of  the  pedicle  was  then  united.  Instead 
of  excising  this  intermediate  piece  of  skin.  Buck  left  it 
attached  by  its  upper  end,  and  used  it  to  cover  part  of  the 
gap  left  upon  the  forehead.  Velpeau  divided  the  pedicle 
close  to  its  base,  trimmed  it  to  a  point,  and  engaged  it  in  a 
vertical  incision  made  in  the  underlying  skin. 

B.  OUiers  Osteoplastic  Method^  (Fig.  128). — A  lupus 
had  destroyed  the  ali^,  columna,  lobe,  cartilages,  and  part 
of  the  septum.  The  nasal  bones  were  uninjured,  but  had 
suffered  an  arrest  of  development,  and  were  bounded  in- 
feriorly  by  a  strip  of  cartilage.  The  nose  was  not  more 
than  an  inch  long.  The  skin  of  the  cheeks  and  lips  had  also 
been  involved  by  the  lupus,  and,  therefore,  could  not  be  used 
for  the  restoration. 

Starting  from  a  point  in  the  median  line  of  the  forehead 
two  inches  above  the  eyebrows.  Oilier  made  two  incisions 
diverging  downward,  each  of  which  ended  a  quarter  of  an 
inch  to  the  outer  side  of  the  lower  border  of  the  nasal 
orifice. 

In  dissecting  up  the  long  triangular  flap  thus  marked  out, 
he  included  the  periosteum  from  above  downward  as  far  as 
to  the  upper  end  of  the  nasal  bones  :  he  then  continued  the 
dissection  along  the  right  nasal  bone,  leaving  the  periosteum 
adlierent  to  it,  and  on  reaching  the  lower  end  of  the  bone  he 

'  Tijiil"''  (le  la  Regeneration  ties  Os,  vul.  ii.  p.  469. 


250         I'LASTIC    OFEKATIOXS    OX    THE    FACE. 

separated  from  it  the  cartilaginous  strip  above  mentioned, 
leaving  it  adherent  to  the  flap. 

On  the  left  side  he  divided,  with  a  chisel,  the  bony  con- 
nections of  the  left  nasal  bone,  leaving  the  bone  attached  to 
the  flap  by  its  anterior  surface ;  this  was  accomplished  by 
introducing  the  chisel,  first  between  the  two  nasal  bones, 

Fig.  128. 


Ehinopla.«t.v.     <  Uliers  osteoplastic  method. 


then  between  the  left  nasal  bone  and  the  frontal,  and 
finally  between  the  left  nasal  bone  and  the  nasal  process  of 
the  superior  maxillary.  Drawing  the  flap  downward,  he  then 
divided  the  cartilaginous  septum  from  before  backward  and 
downward  with  scissors,  so  as  to  have  an  antero-posterior 
flap  of  cartilage  attached  by  its  base  to  the  cutaneous  one, 
and  able  to  furnish  central  support  for  the  new  nose  by  rest- 
ing its  free  border  upon  the  floor  of  the  nasal  fossa,  or  rather 
upon  the  remains  of  the  lower  portion  of  the  original  septum. 

He  ne:tt  drew  the  whole  flap  downward  until  the  upper 
border  of  the  left  nasal  bone  came  into  line  with  the  lower 
border  of  the  right  nasal  bone,  and  then  fastened  the  two 
bones  together  with  a  metallic  suture.  The  sides  of  the 
flap  were  then  united  to  the  cheeks,  and  those  of  the  frontal 
incisions  drawn  together  above  the  apex  of  the  flap. 

The  parts  united,  the  space  left  l)y  the  removal  of  the 
left  nasal  bone  was  filled  with  bone  })roduced  by  the  perios- 


Hill  NO  TLA  STY 


251 


teuni  bnniirl't  down  from   tlio  forclioad.  and   tin*  result  was 
sutistactorv. 

C.  AUjuie  used  a  llaj)  of  similar  sha})e  in  a  case  in  which 
the  alae  and  septum  were  lost,  but  the  columna  remained. 
The  apex  of  the  triangle  was  })laeed  in  the  spaee  between 
the  eyebrows,  and  the  incisions  diverfred  downward  and  out- 
ward.  With  a  narrow  tenotome  passed  along  the  incisions 
he  separated  the  skin  entirely  from  the  nasal  bones  and  was 
then  able  to  dejn-ess  it  far  enough  to  attach  it  to  the  fresh- 
ened end  of  the  columna. 

D.  Italian  Method  (Fig.  12l>). — Tagliacozzi  made  two 
nearly  parallel   incisions  tilong  the  anterior  surface  of  the 

Fig.  129. 


Rhinoplasty.     Italian  meth(xl. 

arm,  their  length  and  the  distance  between  them  varying 
according  to  the  size  of  the  gap  the  Hap  was  to  fill.  The 
apex  of  the  flap  was  directed  toward  the  shoulder.  The 
intermediate  strip  of  skin  was  dissected  up,  but  left  adherent 
at  both  ends,  and  a  piece  of  oiled  lint   passed  under  it  and 


252         PLASTIC    OPERATIONS    ON    THE    FACE. 

kept  there  until  siippumtion  was  established.  The  strip 
was  then  cut  free  at  its  upper  end,  and  dressed  carefully  for 
about  a  fortnight,  or  until  its  under  surface  was  nearly  cica- 
trized. It  was  then  considered  fit  to  be  applied,  having 
undergone  the  necessary  shrinking  and  thickening.  Its 
edges  and  those  of  the  nasal  aperture  were  pared  and  fast- 
ened together  with  sutures,  and  the  arm  bound  fast  to  the 
head.  When  union  had  taken  place  between  the  tAvo.  the 
lower  end  of  the  flap  Avas  cut  loose  from  the  arm  and  its 
edges  trimmed  to  the  proper  shape. 

Graefe  did  not  let  the  flap  suppurate,  but  tried  to  get 
primaiy  union. 

Dr.  Thomas  T.  Sabine  has  successfully  filled  by  the  im- 
plantation of  a  finger  the  gap  left  by  the  destruction  of  the 
nose. 

PLASTIC  OPERATIONS  UPON  THE  EYELIDS. 

In  these  operations  it  is  important  to  save  as  much  as 
possible  of  the  original  tissues,  especially  the  free  border  of 
the  lid,  the  conjunctiva,  and  the  orbicular  muscle.  As  the 
skin  is  thin  and  delicate,  the  flaps  must  bave  broad  bases  to 
insure  their  vitality ;  they  must  also  be  so  placed  that  their 
natural  retraction  will  not  tend  to  reestablish  the  previous 
defect. 

Blepharorapliij. — Suture  of  the  eyelids  has  proved  a  very 
valuable  adjunct  of  many  of  the  plastic  operations  upon  the 
eyelids,  and  has  even  taken  the  place  of  some  of  them,  for 
experience  has  shown  that  a  loss  of  substance  in  either  eye- 
lid may  be  safely  allowed  to  fill  and  heal  by  granulation  if 
the  borders  of  the  lids  are  kept  fastened  together.  The  eye 
must  be  kept  closed  in  this  way  for  six  months  or  a  year, 
after  which  time  the  scar,  in  most  cases,  shows  no  tendency 
to  retract.  AVhen  the  time  comes  to  separate  the  lids,  this 
should,  at  first,  be  done  for  only  half  an  inch  in  the  centre, 
and  the  opening  subse(|uently  enlarged  at  long  intervals  of 
time,  any  indication  of  cicatricial  retraction  being  meanwhile 
watched  for. 

The  prolonged  occlusion  does  no  harm  to  the  eye ;  on 
the  contrary,  it  may  be  sufficient  in  itself  to  cure  a  com- 
mencing keratitis  occasioned  by  ectropion. 


PLASTIC   OPERATIONS   UPON   TIIK   EYKLIDS.      258 


Operation. — A  imnow  strip  of  conjiuicliva  is  excised 
from  tlie  border  of  eaeli  lid  on  llie  conjuiK'tivMl  side  of  tlic 
laslies,  beiriiiniiiii:  and  eiidiiiii"  a  sliort  distance  from  the  com- 
missures,  so  as  to  leave  a  space  for  the  lh)W  of  the  tears. 
The  two  raw  surfaces  are  tlien  hrouglit  toj^ether  accurately 
wit) I  silver  sutures. 

To  separate  the  lids  afterward  a  director  should  he  en- 
tered at  the  openiui;-  left  at  one  of  the  angles,  its  point 
pressed  against  the  centre  of  the  line  of  iniion,  and  cut 
down  upon  the  two  rows  of  lashes. 

Canthoplasty. — Enlargement  of  the  palpebral  opening 
(Fig.  180).     The  external  angle  of  the  eye  is  divided  hori- 

FiG.  130. 


Canthoplasty.    A.  Straiglit  iiici-siou.     B.  Richet's  modification. 

zontally  with  scissors,  and  the  skin  and  conjunctiva  united 
along  the  sides  of  the  incision  by  three  points  of  sutures, 
one  of  them  being  placed  at  the  angle. 

Richet's  modification^  (^^g-  1*^^7  ^)-  Richet  marks  out 
a  small  flap  by  two  incisions  through  the  skin,  beginning  at 
opposite  points  on  the  upper  and  lower  lids  near  the  outer 
angle  and  meeting  at  a  point  external  to  that  angle.  The 
flap,  including  everything  except  the  conjunctiva,  is  then  ex- 
cised, the  conjunctiva  split  horizontally,  and  its  two  portions 
trimmed  and  fastened  to  the  edge  of  the  cutaneous  incisions. 

Blepharoplasty^  to  prevent  or  remedy — 

1.  Ectropion. — The  descriptions  will  be  given  for  the 
lower  lid  only,  that  being  the  more  frequent  seat  of  the  de- 
formit}^     Blepharoraphy  (q.  v.)  is  often  sufficient  in  itself 

^  Anatomie  Medico-Chirurgicale,  4th  edition,  p.  88. 

22 


254 


PLASTIC    OPERATIONS    OX    THE    FACE 


to  prevent  ectropion,  and  is  ahvays  a  useful  adjunct  of  a 
plastic  operation.  The  lids  should  be  kept  united  during 
the  process  of  cicatrization  of  the  wound  left  by  the  loss  of 
substance,  and  for  several  months  tliereafter. 

Wharton  Jones  (Fig.  131). — Wharton  Jones  included 
the  contracted  cicatrix  in  a  triangular  flap  one  inch  high, 
it?  base  occupying  nearly  the  whole  length  of  the  lid  border. 

Fig.  131. 


lx;ti'oi>iou.     Walter  Jones. 

By  dividing  the  bands  of  cellular  tissue,  but  without  dis- 
secting up  the  flap,  he  restored  the  lid  to  its  normal  position, 
and  held  it  there  by  uniting  the  edges  of  the  incisions  below, 
thus  giving  it  the  form  of  a  Y. 
.  AJphonse  G-uerin^  (Fig.  132)  makes  two  incisions  form- 
ing an  inverted  V,  the  point  of  which  lies  just  below  the 

Fig.  132. 


Ectropion.     Alphonse  Guerin. 

centre  of  the  free  border  of  the  lid.     From  the  lower  ex- 
tremities of   these  incisions   he  makes  a   third   and  fourth 


'  Chirurgie  Operatoire,  4th  edition,  p.  318. 


PLASTIC   OPK  RATIONS    ITI'ON    THE    EYKLIDS.       255 

])arallc'l  to  tlie  bonier  of  the  lid.  The  two  triaiiL^ilar  Haps 
boiindcd  by  the  1st  and  8d,  and  the  '2d  and  4th  incisions 
are  then  dissected  up,  the  lid  raised  to  its  normal  position, 
and  held  there  by  uniting  the  adjoining  sides  of  these  two 
Haps  in  such  manner  tliat  their  apices  and  that  of  tlie  in- 
verted V  meet  at  a  connuon  point.  The  gaps  left  by  tlie 
removal  of  the  two  flaps  are  allowed  to  granulate.  For 
greater  security  Guerin  also  unites  the  borders  of  the  lids 
(blepharoraphy). 

Vo7i  Grarfe  (Fig.  138,  A). — Make  an  incision  along  the 
border  of  the  lid  just  outside  of  the  lashes  from  the  lacli- 


P^ia.  133. 


Ectropion.      A,  Von  Gracfe's  metliod.     B.  Knapp's  inetliod. 

rymal  point  to  the  external  commissure.  From  each  ex- 
tremity of  this  make  a  vertical  incision  downward  from  one- 
half  to  three-quarters  of  an  inch  in  length.  These  incisions 
should  involve  only  the  skin.  Cut  oft"  the  upper  inner  cor- 
ner of  this  flap,  not  by  a  straight  incision,  but  by  one  form- 
ing an  angle,  as  show^n  in  the  figure,  and  fasten  this  angle 
by  a  suture  to  that  formed  by  the  border  of  the  lid  and  the 
inner  vertical  incision.  Reunite  the  edges  of  the  transverse 
incision,  cuttino;  the  ends  of  the  sutures  lonfii;  enoufjh  to 
reach  to  the  forehead,  and  then  fastening  them  there  with 
adhesive  plaster.  The  excision  of  the  inner  angle  of  the 
flap  raises  the  eyelid  by  shortening  its  border. 

Dieffenbach,  Adams,  and  Ammon  have  proposed  other 
methods  of  shortening  the  lid.  They  are  indicated  in  Fig. 
134,  where  the  shaded  spaces  represent  the  portions  of  skin 
to  be  removed,  and  the  threads  the  manner  in  which  tlie 
edges  arc  afterward  l>i'ought  together.  Adams's  excision 
included  the  Avhole  thickness  of  the  lid. 


256 


PLASTIC    OPERATIONS    OX    THE    FACE 


Richet  (Fig.  135). — Richet  makes  an  incision  parallel  to 
the  border  of  the  lid,  half  an  inch  below  it,  and  extending 
nearly  from  one  angle  of  the  eye  to  the  other.  The  lid, 
having  been  freed  by  this  incision,  is  then  united  to  the 
other  { blepharoraphv ). 


Fig.  l?A. 


a  i^  B 

Ectropion.    A.  DiefFenbach.     B.  Adams.     C.  Amn.fn.     The  shaded  qiaces  indicate  the 
portions  of  ekin  remored  :  the  threads  show  liow  their  edges  are  brought  together. 


He  next  makes  a  second  incision  parallel  to  the  first  and 
one-third  of  an  inch  below  it,  divides  the  intermediate  strip 
of  skin  vertically  in  the  middle  and  dissects  up  its  two 
halves.      Immediately   below  the  lower  end  of  this  vertical 


Fig.  135. 


Ectropion.     Bichet. 


incision  he  removes  fr( jui  the  lower  border  of  the  second 
incision  a  V-s?haped  flap  of  skin,  its  point  directed  down- 
ward. He  then  raises  the  two  halves  of  the  middle  flap, 
brings  them  again  into  contact  with  the  border  of  the  lid, 
excises  their  su})erfluous  length,  and  unites  them.  The 
sides  of  the  Y  are  then  brought  together  and  the  edges  of 
the  incisions  reunited. 


PLASTIC   OPERATIONS   UPON   TlIK    KYKLIDS 


257 


Kwipp  (Fig.  1'3:>,  B). — Kii;i|)})  c'lnploytMl  the  loll(nv- 
ing  method  to  remove  an  epitlielioma  occupying  the  inner 
portion  of  the  h)wer  eyelid,  the  free  border  of  which  was 
involved.  He  circumscribed  the  tumor  In'  two  vertical  and 
two  horizontal  excisions  and  excised  it.  The  horizontal  in- 
cisions were  then  prolonged  on  both  sides,  the  lower  external 
one  being  inclinetl  downward  so  as  to  make  the  base  of  the 
flap  broader,  the  two  Haps  dissected  up,  drawn  together  and 
united  by  their  vertical  edges. 

Burow  (Fig.  1-^0). — The  loss  of  substance  is  made 
triangular  in  shape,  the  apex  directed  downward  ;  the  base 
is  then  i)rolonged  horiz(intally  outward,  and  an  equal  and 
similar  triangle  marked  out  upon  the  upper  side  of  the  pro- 

FiG.  13(3. 


Ectropion.     Burow. 

longation.  The  skin  contained  within  the  second  triangle 
is  then  excised,  and  the  irregular  flap  bounded  by  the  outer 
sides  of  the  two  triangles  and  the  prolongation  of  the  hori- 
zontal incision  dissected  outward  and  downward,  and  then 
moved  toward  the  median  line  until  it  covers  both  the  open 
spaces. 

It  is  not  necessary  that  the  two  triangular  spaces  should 
touch  at  one  corner ;  they  may  be  an  inch,  or  even  more, 
apart;  but  they  must  of  course  be  connected  by  the  hori- 
zontal incision. 

Dieffenbach  (Fig.  187). — When  the  cicatrix  or  tumor 
was  larore  Dieffenbach  jjave  the  loss  of  substance  a  trian- 
gular  shape,  the  apex  directed  downward.  He  prolonged 
outward  the    horiz(jntal    incision    forming  the  base  of  the 

22* 


258 


PLASTIC  OPERATIONS  ON  THE  FACE 


triangle,  and  carried  another  incision  downward  and  inward 
from  its  outer  extremity.  The  (juadrilateral  flap  thus 
marked  out  was  dissected  up  and  carried  inward  to  cover 


FiQ.  137. 


Ectropion.     Dieffenbach 


the  loss  of  substance.  The  gap  left  by  its  removal  was 
then  drawn  partly  together  with  sutures,  and  the  remainder 
left  to  granulate. 

Indian  Method. — Sedillot  refers  the  first  blepharoplasty 
by  the  Indian  method  to  Von  Graefe  in  1809.  As  this  was 
previous    to  the    introduction  of  rhinoi:)lasty  by  the    same 

Fig.  138. 


Ectropion.     A.  Modified  Indian  ^Metliod.     B.  Eichet. 

method,  the  idea  was  probably  entirely  original  with  Yon 
Graefe.  The  case  is  mentioned  in  his  BJiinopIastik^  1818, 
but  without  details.  The  flap  can  be  taken  from  the  fore- 
head or  cheek  ;  it  should  be  very  large  and  should  include 
the  subcutaneous  cellular  tissue.  Fricke,  of  Hamburg,  took 
a  vertical  flap  from  the  temporal  region  to  restore  the  upper 
eyelid. 


PLASTIC  OPERATIONS  UPON   THE   EYELIDS.      259 

Olio  of  tilt'  modifications  of  tliis  method,  intoiidc<l  to  ob- 
viate the  necessity  of  dividing  the  pedicle,  is  shown  in  Fi". 

Rich't  (Fig.  138,  B). — The  lids  are  freed  l)y  two  in- 
cisions inclosing  all  the  cicatricial  tissue,  and  then  united 
(blepharoraj)hy),  the  sutures  being  cut  long  and  their  ends 
fastened  upon  the  forehead.  Two  flaps  are  then  marked 
out  as  shown  in  the  figure,  the  external  one,  (7,  raised  and 
used  to  cover  the  original  loss  of  su])Stance,  and  the  inner 
one,  D,  used  to  fill  the  gap  occasioned  by  the  removal  of  C. 

Ha^^wr  d" Artha  (Fig.  139)  employed  the  following 
method  in  a  case  where  -a  tumor  occupied  the  commissure 
and  inner  portion  of  each  eyelid.  He  made  a  curved  in- 
cision, a,  beginning  at  the  border  of  the  upper  eyelid 
beyond  the  limit  of  the  tumor,  crossing  the  eyebrow  to  the 


Fig.  139. 


Ectropion.     Hasner  d'Artha'.s  method. 

forehead,  and  then  crossincr  downward  to  terminate  near  the 
root  of  the  nose.  A  second  curved  incision,  e,  began  at  the 
same  point  as  the  first  and  was  carried  along  the  upper  and 
inner;  edge  of  the  tumor  to  the  point  marked  f.  A  third 
curved  incision,  e.  began  on  the  border  of  the  lower  lid 
beyond  the  limit  of  the  tumor  and  was  carrieil  along  the 
lower  margin  of  the  latter  to  the  point  /.  A  fourth  curved 
incision,  </,  parallel  to  the  border  of  the  lower  lid,  was  car- 
ried from  the  point  f  outward  to  the  cheek. 

The  tumor  and  the  portion  of  the  lids  circumscribed  by 
the  incisions  '-  ami  e  were  then  remove*!,  and  each  of  the 
flaps  d  and  h  dissected    up  to  its  base.     The  former  was 


260 


PLASTIC  OPERATIONS  ON  THE  FACE 


lowered,  the  latter  raised,  and  the  excess  of  each  cut  off. 
The  upper  border  of  the  flap  h  formed  the  free  border  of 
the  lower  lid,  and  the  lower  border  of  the  flap  d  formecj  the 
free  border  of  the  upper  lid,  and  the  commissure  corre- 
sponded to  the  apex  of  the  flap  h.  The  skin  of  the  fore- 
head and  cheeks  Avas  mobilized  and  reunited  to  the  flaps 
(Dubrueil). 

DeJionvilliers  s  method  "by  exchange"  (Fig.  140).  In 
a  case  of  ectropion  of  the  lower  lid,  with  deviation  of  the 
outer  angle  of  the  eye  downward,  Denonvilliers  used  the 
following  method.  By  making  three  incisions  to  meet  in 
the  form  of  a  Z,  he  marked  out  two  adjoining  triangular 
flaps ;  one  of  them  included  the  outer  angle  of  the  eye,  the 

Fig.  140. 


Ectropion.     Denonvilliers's  method  "bj' exchange." 

apex  of  the  other  was  situated  upon  the  forehead  just  above 
thevCyebrow.  He  then  dissected  up  the  flaps,  restored  the 
angle  of  the  eye  to  its  proper  position,  brought  the  upper 
flap  down  into  the  gap  made  by  the  lower  incision,  and  the 
lower  flap  up  into  that  made  by  the  upper  incision. 

Ectropion  due  to  excess  of  the  conjunctiva  may  be  treated 
by  cauterization  of  the  conjunctiva,  or  by  excision  of  a 
portion.  The  latter  operation  is  simple ;  a  fold  is  pinched 
up  with  forceps  and  excised  w^itli  knife  or  scissors.  The 
edges  of  the  gap  may  then  be  brought  together  by  sutures 
or  left  to  granulate. 

2.  Entropion. — OanthopJasty  (</.  v.)  may  be  employed 
to  remedy  moderate  entropion,  especially  if  it  be  due  to 
spasm  of  the  orbicularis. 


riiASTlU   orKKATlONS    UTON    TilK    K^'KI.IDS         2G1 

Lijldtfire  (Fi.1!;.  141),  ])i-()p()S('(l  by  (JmiIImimI  to  rcnu'dv 
tiK-liiasis,  is  c(|ii;illy  applicable  to  tbc  cure  of  entropion. 
A  transverse  fold  is  pinehed  up,  and  a  needle  carry in;z;  a 
stout  ligature  passed  tlirou«!;li  its  base,  sliaving  the  anterior 
surface  of  the  cartilao;c.  The  ligature  is  ti(Ml  and  allowed 
to  cut  throuirh  the  skin.  The  residtiiig  linear  cicatrix 
maintains  the  lid  in  the  position  given  it  by  the  ligature. 

Kau  has  modified  this  by  placing  several  ligatures  instead 
of  only  one. 

Fig.  141. 


Entropion  ;  ligature. 

Excision  or  cauterization  of  a  fold  of  the  skin  is  appli- 
cable to  cases  of  entropion  due  to  laxity  of  the  skin  of  the 
eyelid.  A  transverse  or  a  vertical  fold  is  pinched  up  <|uite 
near  to  the  margin  of  the  lid  and  excised ;  the  borders  of 
the  wound  are  united  by  sutures.  Instead  of  excision,  cau- 
terization of  the  strip,  preferably  with  sulphuric  acid,  is 
sometimes  used. 

Von  (xraefe  (Fig.  142)  treated  a  case  of  spasmodic 
entropion  by  removd  of  a  triangular  piece  of  skin,  lie 
made  a  cutaneous  incision  parallel  to  the  free  border  of  the 
lid,  and  about  a  line  from  it,  and  excised  a  triangidar  cuta- 
neous Hap,  the  l^ase  of  which  occupied  the  median  ])ortion 
of  the  first  incision.  The  sides  of  the  wound  left  by  the 
excision  of  the  triangular  piece  were  then  drawn  together 
with  sutures. 

For  spasmodic  entropion  of  the  upper  lid,  with  i-etraction 
of  the  tarsal  cartilage,  A'on  Graefe  modified  the  operation 
as  follows  (Fig.  148):  After  excision  of  the  ti-iangnlar 
cutaneous  Hap,  he  drew  the  sides  of  the  wound  at)art,  divided 
the  orbicular  muscle  horizontally  near  the  e<lge  of  the  lid, 
and  drew  it  u])ward,  exposing  the  cartilage.  He  then  ex- 
cised a  triangular  piece  of  the  cartilage,  the  apex  being  at 


2(32 


PLASTIC  OPEKATIUNS  ON  THE  FACE. 


its  lower  border,  taking  care  not  to  include  the  conjunctiva 
in  the  dissection.  The  sides  of  the  cutaneous  wound  were 
then  drawn  together  with  three  sutures,  the  middle  one  of 
which  included  also  the  sides  of  the  gap  left  in  the  cartilage. 


Fig.  142. 


Fig.  U.3. 


Entropion — lower  lid.     Von  Graefe. 


Entropion — upper  lid.     Von  Graefe. 


Excision  of  a  Portion  of  the  Orbicularis. — Key  cured  a 
case  of  spasmodic  entropion  bv  excising  a  few  fibres  of  the 
orbicular  muscle.  He  made  an  incision  through  the  skin 
parallel  to  and  near  the  free  border  of  the  lid,  exposed  the 
muscle,  and  removed  a  bundle  of  fibres  from  its  central 
margin.  It  is  well  to  combine  this  with  removal  of  a  hori- 
zontal strip  of  skin. 

Division  or  Resection  of  the  Tarsal  Cartilage. — When 
the  entropion  is  caused  or  maintained  by  shortening  or  in- 
curvation of  the  tarsal  cartilage,  the  operation  must  be 
directed  to  the  removal  of  this  cause. 

Vertical  division  at  one  or  two  points  of  the  entire  thick- 
ness of  the  lid  has  been  employed.  After  having  been 
divided,  the  border  of  the  lid  is  held  in  its  proper  position 
by  ligatures  passed  through  it  and  fastened  to  the  forehead 
(upper  lid)  or  cheek  (lower  lid)  wliile  the  wound  fills  and 
heals  by  granulation. 

A  horizontal  incision  through  the  conjunctiva  from  one 
vertical  incision  to  the  other  makes  it  easier  to  turn  the  lid 
out  and  hold  it  in  place. 

LoHjiitudinal  Tarsotomy  (Amnion). — The  eyelid  having 
been  turned  out,  a  knife  is  passed  through  it  from  the  con- 
junctival side,  quarter  of  an  ineli  from   the   border,  and  on 


PLASTIC  OPERATIONS   IM'ON   THE    EYELIDS.       2Go 


a  line  with  the  hiehryinal  jjoiiit,  and  an  incision  nia«le  pamllel 
with  till'  border  nearlv  to  tlie  outer  anirle.  A  l<»n<Mtudinal 
strip  of  skin  is  then  excised,  and  the  ed<^es  of  the  gajj  left 
by  the  excision  are  drawn  together.  By  this  means  the 
free  border  of  the  lid  is  drawn  away  from  the  surface  of  the 
eye.  turning  uprm  the  longitudinal  incision  as  upon  a  hinge. 

Fig.  144. 


::> 


Knapp's  modification  of  Desmarres's  forceps. 

Excision  of  part  of  the  Cartilage  (Streatfeild),  (Fig.  145.) 
— The  eyelid  is  fixed  with  DesmaiTess  forceps  (Fig.  144),  the 
flat    blade   against   the  conjunctiva,  and  an  incision  made 
parallel  to  the  border  of  the  lid  at  the  distance  of 
one  line  from  it,  and  carried  to  a  depth  sufficient 
to  expose  the  bulbs  of  the  eyelashes.     The  sur- 
geon, raising  the  edge  of  the  skin,  passes  around 
the  bulbs  to  the  tarsal  cartilage,  and  then  makes  a 
second  incision  at  a  greater  distance  fi'om  the  bor- 
der of  the  lid  than  the  first  one  was,  meeting  the  .\ 
fii*st  at  its  two  extremities  and  inclosing  with  it  an        '      ; 

oval  strip  of  skin.    These  two  incisions  are  carried      *" ^j 

into  the  cartilage,  circumscribing  a  longitudinal  ^ 

wedge-shaped  strip,   the    apex  of  which    reaches     Entn..piun. 
nearlv  to  the  conjunctival  side  of  the  cartilage.    ^»'^tf«"«*"'' 
The  wound  is  left  to  heal  by  granulation,  with  the 
expectation  that  the  contraction  of  the  cicatrix  will  overcome 
the  entropion. 


3.  Symhhpharon. — AVhen  the  adhesion  between  the  two 
layei*s  of  the  conjunctiva  is  incomplete,  that  is,  when  it 
does  not  extend  to  the  bottom  of  the  sulcus  between  the  lid 
and  eyeball,  it  is  sufficient  to  throw  a  ligature  around  it. 
After  the  ligature  has  cut  through,  the  tabs  are  successively 


264 


PLASTIC    OPERATIONS    ON    THE    FACE 


excised,  and  the  borders  r>f  each  wound  drawn  together  or 
left  to  heal  bv  crranulation.  To  avoid  reunion  of  the  sur- 
faces,  the  second  tab  should  not  be  removed  until  after  the 
wound  left  by  the  removal  of  the  first  ha,s  healed. 

When  the  adhesion  is  complete,  but  not  broad,  a  thread 
or  silver  wire  may  be  passed  through  its  Ijase  and  tied 
loosely  around  it.  After  the  hole  made  by  the  wire  has 
cicatrized  the  adhesion  is  divided.  The  narrow  line  of  cica- 
trix left  at  the  bottom  of  the  fold  by  the  wire  favors  the 
separate  healing  of  the  two  sides  of  the  incision. 

Arlt's  JletJiod. — A  thread  is  passed  through  the  fold 
close  to  tlie  cornea,  and  the  symblepharon  dissected  away 
from  the  eyeball.  Each  end  of  the  thread  is  then  attached 
to  a  needle  and  passed  through  the  lid  from  within  outward 
at  the  bottom  of  the  wound.  By  drawing  upon  the  thread 
and  tying  it  outside  the  lid  the  symblepharon  is  folded  upon 
itself  and  its  point  fixed  at  the  bottom  of  the  sulcus.  The 
edcres  of  the  Avound  on  the  eveball  are  then  drawn  tou;ether 
with  sutures,  the  conjunctiva  being  loosened  by  dissection,  if 
necessarv. 

Tealc's  Method  (Figs.  14u,  147,  148j.— The  symble- 
pharon is  separated  from  the  ball  of  the  eye  by  an   incision 


Fig.  U  k 


Fig.  147 


Symblepliaiou. 


7>/  x    M^, 

B,  C    The  flaps 


along  the  line  of  its  union  with  the  cornea  and  dissected 
down  to  the  bottom  of  the  fold  as  in  Arlt's  operation,  its 
apex,  however,  being  left  upon  the  cornea.  Two  long,  nar- 
row conjunctival  flaps,  B  and  (7,  are  then  dissected  up  on 
opposite  sides  of  the  eyeball,  their  bases  directed  toward  the 
symblepharon.  their  borders  parallel  to  that  of  the  cornea. 
These  flaps  should  not  include  the  subconjunctival  tissue. 


PLASTIC   OPERATIONS   UPON   THE    EYELIDS.       2(j5 

The  inner  llap  H  is  Idoiiulit  down  and  fastened  to  the  de- 
nuded surtace  of  the  eyehd,  the  outer  llap  0  covers  that  of 
the  eyehall.  fhey  are  fastened  in  place  hy  means  of  lin(i 
sutures,  and  the  edij;es  of  the  i^aps  h-ft  hy  their  i-enioval 
l)rou«fht  toujether  in  the  same  niunner. 


Flaps  in  place. 

Ledcntus  Operation. — Where  one  lid  was  adherent 
throughout  its  entire  lenL!.th,  Ledentu  divided  the  adhesion 
to  a  depth  e(|ual  to  that  of  the  normal  fold,  dissected  a  long 
conjunctival  flap  from  the  other  half  of  the  eye,  leaving  it 
adherent  at  both  ends,  brought  it  down  across  the  cornea, 
and  applied  it  to  the  raw  surface  left  on  the  eyeball  by  the 
division  of  the  adhesion.  This  flap  should  be  at  least  one- 
third  of  an  inch  broad. 

4.  Pterygion.  Excision. — The  pterygion  is  pinched  up 
with  forceps,  a  knife  passed  flatwise  under  it  close  to  the 
cornea,  and  the  portion  of  the  growth  which  corresponds  to 
the  latter  shaved  off".  The  edges  of  the  conjunctival  wound 
are  then  drawn  together  with  sutures. 

Scissors  may  be  used  instead  of  the  knife :  in  that  case 
the  incision  must  begin  at  the  point  of  the  growth. 

Ligature^  Szokalski  (Fig.  14*J). — A  thread  is  pjissed 
under  the  pterygion  by  means  of  two  small  curved  needles, 
as  shown  in  Fio".  149.  The  thread  is  cut  close  to  the  nee- 
dies,  and  thus  made  to  furnish  three  ligatures,  one  at  each 
end,  encircling  the  crrowth  at  riu'ht  anijles  to  its  long  axis, 
and  one  in  the  middle,  encircling  its  implantation  upon  the 
sclerotic.  The  ligatures  are  tied  tightly,  and  the  inclosed 
portion  falls  in  a  few  days. 

o.  Trirhiasis. — Temporary  removal  of  the  deviated  la.slies 
is  seldom  eff'ectiial.      Permanent  removal  by  destruction  of 

23 


26') 


PLASTIC    OPERATIONS    OX    TIfE    FACE 


their  bulbs,  or  excision  of  tlie  border  of  tlie  lid,  is  now  con- 
sidered unjustifiable.  The  direction  of  the  lashes  may  be 
changed  by  operation  upon  the  lid.  The  retraction  follow- 
ing excision  of  an  oval  strip  of  skin,  or  the  use  of  ligatures 


Fig.  149. 


Pteryofiou  ;  liorature. 


as  in  entropion,  is  sometimes  sufficient,  but  it  may  be  neces- 
sary to  act  more  directly  upon  the  lashes. 

Von  Graefes  Metliod. — An  incision  is  made  along  the 
free  border  of  the  lid  on  the  conjunctival  side  of  the  devi- 
ated lashes.  From  each  end  of  this  a  vertical  incision  is 
next  made  through  the  free  border  and  the  skin.  The  flap 
thus  circumscribed  and  containing  the  lashes  is  dissected  up 
a  short  distance.  It  is  then  easy  to  fasten  it  with  sutures 
in  such  a  position  that  the  lashes  can  no  longer  touch  the 
eyeball. 

Anafinostakis  made  a  cutaneous  incision  parallel  to  the 
border  of  the  upper  lid  and  one-eighth  of  an  inch  from  it, 
exposed  the  orbicular  muscle  by  drawing  the  skin  up,  and 
excised  that  portion  of  it  which  corresponded  to  the  upper 
part  of  the  tarsal  cartilage.  The  lower  edge  of  the  cuta- 
neous incision  was  then  drawn  up  and  fixed  to  tlie  fibr<:)- 
cellular  laver  coverino;  the  cartilasje  bv  means  of  three  or 
four  sutures,  which  were  then  allowed  to  cut  tliem.selves  out. 


PvVllT    YIl. 
8PEC1AJ.  01M<:ilAT10NS. 


CILArTEll    I. 

OPERATIONS  UPON  THE  EYE  AND  ITS  APPENDAGES. 

Ix  most  operations  upon  the  eye  the  lids  should  be  held 
back    by  an    cye-speculuni    (Fig.    150),    and    the   eyeball 

Fig.  150. 


Eye  speculum. 

fixed  by  pinching  up  a  fold  of  the  conjunctiva  with  toothed 
forceps. 

The  instillation  of  a  few  drops  of  a  four  per  cent,  solution 
of  the  hydrochlorate  of  cocaine  under  the  lids  will  make 
most  operations  painless,  but  the  sensitiveness  of  the  iris  is 
not  thereby  abolished. 

THE  CORNEA. 

Removal  of  a  Foreign  Body. — When  the  foreign  body  has 
penetrated  to  only  a  slight  depth,   it  may  be  easily  removed 


268  OPERATIONS    UPON    T  H  R    EYE. 

with  the  point  of  a  kniib  or  fine  forceps ;  hut.  if  it  lies  so 
near  the  posterior  surface  of  the  cornea  that  there  is  danirer 
of  forcin^o;  it  through  into  the  anterior  chamber  b}^  the  efforts 
made  for  its  extraction,  a  lance-shaped  knife  must  be  entered 
very  obli([uely  and  passed  behind  it,  between  the  layers  of 
the  cornea  if  there  is  sufficient  space,  otherwise  Avithin  the 
anterior  chamber. 

If  the  foreign  body  falls  into  the  anterior  chamber,  not- 
withstanding these  efforts  to  prevent  it,  the  surgeon  must 
wait  until  the  aqueous  humor  has  reaccumulated,  and  then 
make  an  incision  three  or  four  millimetres  in  length  at  the 
lower  portion  of  the  periphery  of  the  cornea,  in  the  hope 
that  the  foreign  body  will  be  washed  out  durinir  the  flow  of 
the  liquid. 

Puncture  of  the  Cornea. — This  may  be  made  with  broad 
needle  or  a  well-worn  Beer's  knife.  It  is  advisable  to  em- 
ploy anesthesia,  and  to  steady  the  eyeball  with  fixation 
forceps.  The  surgeon  stands  behind  the  patient,  raises  the 
upper  lid,  and  fixes  it  against  the  margin  of  the  orbit  with 
two  fingers  of  his  left  hand,  Avhich  also  rest  against  the  inner 
side  of  the  eyeball  and  prevent  it  from  rotating  inward. 
The  needle  or  knife  is  then  entered  a  little  in  front  of  the 
edge  of  the  cornea  at  the  outer  side.  Its  direction  must  be 
sufficiently  oblique  to  avoid  injury  to  the  iris,  and  not  so 
much  so  that  the  instrument  Avill  remain  between  the  layers 
of  the  cornea  and  fail  to  penetrate  to  the  anterior  cham- 
ber. By  partly  withdrawing  the  instrument  and  twisting  it 
slightly,  the  incision  is  made  to  gape  and  allow  the  escape 
of  the  liquid ;  or  a  fine  blunt  probe  may  be  passed  into  the 
incision  after  entire  withdrawal  of  the  needle.  Subse([uent 
tappings  are  effected  by  reopening  the  original  wound  with 
the  probe.  Figure  151  represents  a  combined  needle  and 
probe.  The  needle  is  provided  with  a  shoulder  to  prevent 
its  introduction  to  too  great  a  depth. 

Removal  of  a  Staphyloma. — The  best  treatment  is  now 
thouo-ht  to  be  enucleation  of  the  eve.  but  evisceration  of  the 
globe  is  sometimes  done. 

Evisceration. — The  sclerotic  is  incised  with  a  Beer's  knife 
just  in  front  of  the  insertion  of  the  external  rectus:  into  the 


TllK    CORNEA.  269 

Fig.  151.  Fiu.  152. 


Stop  nettlle  and  probe  for 
pancturiDg  the  cornea. 


Beer's  knife. 


2a* 


270  OPERATIONS    UPON    THE    EYE. 

opening  is  passed  one  blade*  of  a  pair  of  small  blunt-pointed 
scissors,  and  the  anterior  portion  of  the  glol)e  is  cut  a^vay, 
with  the  lens  and  all  tlie  vitreous  humor.  The  Avound  is 
then  closed  witli  catgut  sutures  passed  through  the  con- 
junctiva alone. 

THE  IRIS. 

Iridotomy. — Incision  of  the  iris  may  be  performed  for  tlie 
purpose  of  establishing  an  artificial  pupil.  As  its  success 
depends  upon  the  retraction  of  the  divided  fibres,  it  should 
be  undertaken  only  when  their  contractility  is  not  interfered 
with  by  too  extensive  adhesions,  or  has  not  been  destroyed 
by  disease.  The  more  common  lesions  to  Avhich  the  opera- 
tion is  applicable  are  central  opacity  of  the  cornea,  occlusion 
of  the  pupil,  and  excessive  prolapse  of  the  iris  after  removal 
of  a  cataract ;  but  the  danger  of  injury  to  the  lens  is  so 
great  that  the  operation  is  practically  restricted  to  the  class 
of  cases  last  mentioned. 

The  best  place  for  an  artificial  pupil  is  in  the  lower  inner 
(juarter  of  the  iris,  the  second  best  in  the  lower  outer 
quarter.  As  the  portion  of  the  cornea  traversed  by  the 
knife  or  needle  is  likely  to  become  more  or  less  opaque  in 
consequence,  the  incision  in  it  should  be  made  as  far  as 
possible  from  the  point  where  the  pupil  is  to  be  created. 

Simple  Incision. — Cheselden,  who  was  the  first  to  per- 
form this  operation,  entered  a  narrow-bladed  knife  through 
the  sclerotic  just  anterior  to  the  insertion  of  the  external 
rectus,  the  point  directed  toward  the  centre  of  the  globe 
of  the  eye.  After  the  point  had  penetrated  to  the  depth 
of  one-eighth  of  an  inch  it  was  directed  forward,  passed 
through  the  iris  to  the  anterior  chamber  and  transversely 
across  the  latter,  its  edge  looking  backward.  By  pressing 
the  edo-e  against  the  iris  and  withdrawincr  it  a  horizontal 
incision  was  made  in  that  membrane. 

Bowman  punctured  the  cornea  midway  between  its  centre 
and  external  border,  passed  a  narrow  blunt-])ointed  knife 
through  the  puncture  into  the  anterior  chamber,  and  thence 
through  the  pupil  to  the  posterior  surfoce  of  the  inner  half 
of  the  iris,  which  he  then  divided  bv  cutting-  forward.  The 
danger  of  injury  to  the  cornea  during  the  last  step  of  the 
operation  is  very  great. 


'I' UK    IK  IS.  271 

Hell'  uses  a  (l()iible-e«lgc(l  iiccdk!  Avliich  is  "  iiitrodiircil 
througli  the  cornea  near  its  ni;!r<i;iii;  on  arriving:  at  tlie 
place  where  the  pupil  oui^ht  to  he,  one  edge  is  drawn 
airainst  the  iris  and  divides  it  transversely,  if  possible,  with- 
out injuring  the  lens." 

Vecker  proposes  simple  iridotorny  and  double  iridotoiny  ; 
the  former  in  cases  of  central  opacity  of  the  cornea  or  lens, 
the  latter  when  the  pupil  has  become  obliterated  after  re- 
moval of  a  cataract,  lie  uses  a  small  lance  sha})ed  knife 
with  a  shoulder,  straight  or  bent  upon  the  Hat,  and  a  pair 
of  force} »s-scissors. 

Simple  Tridotoiin/  (Wecker). — The  knife  is  entered  mid- 
way between  the  centre  and  border  of  the  cornea  on  the 
side  opposite  to  that  on  which  the  pupil  is  to  be  made.  As 
soon  as  the  cornea  has  been  perforated  the  knife  is  with- 
drawn and  the  forceps-scissors  ])assed  through  the  wound 
to  the  further  border  of  the  pupil,  where  they  are  opened 
and  one  of  the  blades  passed  behind,  the  other  in  front,  of 
the  iris.  By  closing  them  sharply  the  circular  fibres  are 
divided  from  the  margin  of  the  pupil  toward  the  periphery 
of  the  iris.  The  scissors  are  then  withdrawn,  the  iris  re- 
placed if  it  engages  in  the  wound,  a  few  drops  of  a  solution 
of  atropine  placed  between,  the  eyelids,  and  a  comju-ess 
applied. 

Double  Iridotorny  (Wecker). — The  knife  is  passed  per- 
pendicularly through  the  cornea  and  iris  one  millimetre 
from  the  edge  of  the  conjunctiva,  on  the  side  toward  which 
the  obliterated  pupil  has  been  retracted ;  its  point  is  then 
made  to  pass  along  the  posterior  surface  of  the  iris  until 
arrested  by  its  shoulder,  when  it  is  withdrawn  slowly.  The 
forceps-scissors  are  next  introduced  through  the  incision, 
and  one  blade  passed  behind  and  the  other  in  front  of  the 
iris  for  a  distance  of  one-([uarter  of  an  inch  or  a  little  less. 
Two  successive  sections  of  the  iris  are  then  made,  inclosing 
a  triangular  flap,  the  apex  of  which  is  directed  toward  the 
incision  in  the  cornea.  The  pupil  is  formed  by  the  retrac- 
tion of  this  flap. 

Iridectomy. — Excision  of  a  portion  of  the  iris  ma}^  be 
employed    for    the  purpose  of  creating  an    artificial   pupil 

^  Manual  of  Surgical  0|)erations,  3d  edition,  p.  l*jU. 


272 


OPERATIONS    UPON    THE    EYE. 


(optical  iridectomy),  or  for  the  reLef  of  tension  in  glaucoma 
or  irido-choroiditis  (antii)hlogistic  iridectomy),  or  as  a  pre- 
liminary to  the  removal  of  a  cataract.^  The  vsize  of  the 
portion  excised  is  determined  by  the  length  and  position  of 
the  line  of  tlie  incision  on  the  posterior  surface  of  the 
cornea ;  the  nearer  this  is  to  the  margin  of  the  cornea  the 
larger  will  be  the  portion  of  the  iris  removed.  In  antiphlo- 
gistic iridectomy,  therefore,  when  the  entire  breadth  of  the 
iris  from  the  pupil  to  its  outer  margin  should  be  removed, 
the  knife  must  be  entered  one  millimetre  outside  of  the 
clear  portion  of  the  cornea  ;  in  optical  iridectomy,  on  the 
other  hand,  the  excised  portion  should  be  small  and  the 
knife  should  be  entered  Avithin  the  margin  of  the  cornea. 
In  antiphlogistic  iridectomy  at  least  one-fourth  of  the  iris 
should  be  removed,  the  piece  being  taken  from  the  upper 
segment  in  order  that  the  loss  may  be  hidden  by  the  upper 
eyelid.  In  optical  iridectomy  the  pupil  should  be  made  on 
the  inner  side  of  the  lower  segment  unless  corneal  opacities 
are  in  the  way. 


Fig.  153. 


Fig.  154. 


\ 


Operation    for  AntipTiJogistic  Iridectomy. — The    instru- 
ments required  are  a  lance-shaped  knife,  straight  (Fig.  153) 

^  For  a  complete  list  of  the  indications  for  iridectomy  the  reader 
is  referred  to  Stellwiii^  on  Diseases  of  the  Eye,  p.  197.  New  York, 
Wm.  Wood  &  Co.,  1868. 


'1  UK    I  i;  IS 


273 


(U-  bfiit  {V'\\i-  l'">4),  iridoctoiny  forceps  (Fi_L^s.  1."),")  miiiI  1.»»»), 
and  sfisxus  curved  upon  tli<'  Hat  (Kig-  l-'T). 


Fits.  loj. 


\     - 


Fig.  158. 


Fui.  I.')";. 


Iridectomv.     Incision  of  curnca. 


Fig.  1')7. 


The  patient  having  been  aninesthetized  and  })laced  ma 
recumbent  posture,  the  surgeon    takes    such  a  position   m 


•274 


Ol'KKATlONS    UrOX    THE    EYE 


front  of  or  behind  liini  as  Avill  facilitate  the  making  of  the 
first  incision.  The  eye  speciihnn  and  fixation  forceps  hav- 
in^T  been  applied,  the  hitter  immediately  ()])posite  the  point 
of  puncture,  the  knife  is  introduced  perpenchcuhirly  to  the 
surface  of  the  sclerotic  one  millimetre  outside  of  the  margin 
of  the  cornea  and  passed  steadily  in  until  its  point  has 
entered  the  anterior  chamber  at  its  very  rim  ;  its  direction 
is  then  changed  and  it  is  carried  alono;  the  anterior  sur- 
face  of  the  iris  until  its  point  reaches  the  centre  of  the 
pupil,  or  until  the  length  of  the  incision  is  considered  suf- 
cient  (Fig.  158).  By  inclining  the  point  of  the  knife  to  each 
side,  the  length  of  the  incision  in  the  posterior  surface  of  the 
cornea  may  be  made  e([ual  to  that  of  the  anterior  surface. 

The  knife  is  then  withdra\Yn  and  the  aqueous  humor 
allowed  to  run  oft"  very  slowly  in  order  that  the  relief  of 
intra-ocular  pressure  may  not  be  so  sudden  as  to  lead  to 
congestion  and  hemorrhage. 

If  the  iris  does  not  now  present  in  the  wound  the  iridec- 
tomy forceps  must  be  introduced  closed  as  far  as  to  the 
maro-in  of  the  pupil,  which  is  then  seized  and  drawn  out 
o-entlv  throuo"h  the  incision.  An  assistant  then  cuts  oft" 
with  the  curved  scissors  all  the  protruding  portion  of  the 
iris  close   to  the    lips   of  the  wound  (Fig.   159).     Or  the 

fixation  forceps  may  be  con- 

FiG.  159.  fided  to  the  assistant  before 

the  introduction  of  the   iri- 


FiG.  100. 


Tync'ir.s  hook 

dectomy  forceps,  and  the 
surgeon  left  free  to  use  the 
scissors  himself.  Instead  of 
the  iridectomy  forceps,  Tyr- 
rell's hook  (Fig.  160)  niay 
be  used  to  di-aw  the  iris  out  throuiih  the  incision.  It  must 
be  introduced  upon  its  side,  hooked  around  the  margin  of 
the  pupil,  and  then  its  point  must  l)e  turned  toward  the 
cornea  and  awav  from  the  centre  of  the  eyeball  so  that  it 


Ifiilectoniv.     Excision  of  the  iris. 


THE    IKIS 


27r, 


will  not  catch  upon  tlic  posterior  ((Iltc  nitlu-  incision  durin;^ 
its  witlulrawal. 

If  anv  lu'niorrlia;!;e  takes   place  into  tlic  antcrioi-  clianil>er 
the  esca})e  of  the  blood  ])cfoi'e  C(>agulation  sliould  l»e  favoii'd 
]>y   separating    the    lips   of  the    incision    witli    a 
curette,    and  making  gentle    pressure    upon    the     ^''<'   I*''- 
eyeball. 

Opticdl  In'dc'-toNii/. — As  only  a  small  central 
portion  of  the  iris  is  to  be  removed,  the  incision 
should  be  made  in  the  cornea  with  a  narrow 
knife  or  a  broa<l  needle  (Fig.  161).  If  the 
margin  of  the  pu}>il  is  adherent,  the  adhesions 
may  be  broken  up  with  a  l)lunt  hook  {Corel t/si><, 
q.  v.),  or  a  portion  of  the  iris,  not  including  the 
margin  of  the  pupil  may  be  pinched  up  and  re- 
moved (Iridorliexis,  q.  v.). 

7n(^or/^rj'/s.— A  modification  of  optical  iridec-    ^r^'i "f^-'.'*" 

f,  ^  .  for      incis- 

tomy  introduced  by  Desmarres  tor  cases  in  winch      iugcomea. 
the   existence  of  adhesions  at  the  margin  of  the 
pupil  or  the  friability  of  the  iris  renders  it  impossible  to  draw 
out  the  latter  throuorh  the  incision  in  the  cornea. 

After  the  incision  has  been  made  in  the  cornea  as  for 
optical  iridectomy,  the  iris  is  seized  near  the  pupil  with  iri- 

FiG.  162. 


Canula  forceps 


dectoniy  or  canula  forceps  (Fig.  162),  drawn  up  into  the 
incision,  and  a  portion  excised  or  torn  oft". 

Iriilesis,  or  displacement  of  the  pupil  by  ligature.      Crit- 
chett,  the  inventor  of  this  operation,  claims'   that  by  it  the 


»  Ophthalmic  IIc.?i,ii.il  lii-ports  vol.  i.  p.  '220. 


276 


OPERATIONS    UPON    THE    EYE. 


size,  form,  and  direction  of  the  pupil  can  be  regulated  to  a 
nicety,  and  its  mol)ility  preserved.  It  is  apjdicable  to  nu- 
merous groups  of  cases  in  which  the  natural  pupil,  or  even 
a  part  thereof,  is  movable,  and  has  a  free  edge;  but  the 
simplest  class  is  that  of  central  opacity  of  the  cornea,  in 
which  it  is  only  required  that  the  natural  pupil  should  be 
moved  slightly  to  one  side,  so  as  to  bring  it  opposite  the 
transparent  part  of  the  cornea.  It  has  also  been  used  in 
cases  of  conical  cornea,  to  change  the  shai)e  of  the  pupil  to 
that  of  a  slit ;  and  in  a  case  where  the  pupil  had  been  ren- 
dered very  small  and  narrow  by  broad  synechiiTe,  Critchett 
made  it  large  and  almost  circular  by  drawing  its  sides  apart 
at  nearly  opposite  points. 

The  operation  is  performed  as  follows : 

An  opening  is  made  with  a  broad  needle  through  the 
margin  of  the  cornea  close  to  the  sclerotic,  and  just  large 
enough  to  admit  the  canula  forceps.  A  small  portion  of  the 
iris  near  but  not  close  to  its  ciliary  attachment  is  seized  and 
drawn  out  to  the  extent  considered  sufficient  for  the  pro- 
posed enlargement  of  the  pupil ;  a  piece  of  fine  floss  silk, 
previously  tied  in  a  small  loop  round  the  canula  forceps,  is 
slipped  down,  and  carefully  tightened  around  the  portion  of 
iris  made  to  prolapse,  so  as  to  include  and  strangulate  it 
(Fig.  163).     This  manoeuvre  is  best  accomplished  by  hold- 

FiG.  103. 


Iridesis. 


ing  each  end  of  the  silk  with  a  pair  of  small  broad-bladed 
forceps,  bringing  them  exactly  to  the  S[)Ot  where  the  knot 
is  to  be  tied,  and  then  drawing  it  moderately  tight.  The 
small  portion  of  the  iris  included  in  the  ligature  speedily 


OPERATIONS   FOR   THK    UKLIKF  OF  CATARAJ  T      li77 

slirinks,  leaving  tlio  little  I'lop  of. silk,  wliicli  may  he  reinovcil 
on  tlio  second  day. 

If  it  is  desired  to  make  tlie  })Uj)il  extend  to  tlie  j)erij>liei*y 
of  the  iris,  the  margin  of  the  ])ii))il  must  be  seized  with  the 
forceps,  and  drawn  out  through  the  incision.  In  (liis  e:ise 
Soelberg  Wells  pi-efers  a   hliinl  hook  to  the  eaiiida  forceps. 

Cf>n'If/.sls,  ov  rupture  of  adhesions  uniting  the  margin  oi' 
the  pupil  and  the  lens.  The  operation  was  first  performed 
by  Streatfeild,  as  follows:*  He  })unctured  the  cornea  with 
a  broad  needle  on  the  outer  side  near  its  margin,  passed  his 
spatula  (Fig.  164)  along  the  anterior  surface  of  the  iris  to 
the  pupil,  engaged  the  adhesions  in  the  notch  on  the  edge 
of  the  s])atula,  and  tore  them.  When  the  entire  margin  of 
the   pupil   was  adherent,   he   passed   the   needle  along   the 

Fig.  1(54. 


Streiitlcilirs  siiutula  hook. 

surface  of  the  iris,  across  the  pupil  to  its  opposite  margin, 
and  cut  the  adhesions  at  that  point.  Then  withdrawing  the 
knife,  he  })assed  the  spatula  through  the  hole  thus  made,  and 
easily  broke  up  the  remaining  adhesions.  When  the  adhe- 
sions were  too  strong  to  be  broken  with  the  s]iatula,  he  used 
the  canula  scissors.  A  few  drops  of  a  solution  of  atro- 
pine should  be  applied  to  the  eye,  both  before  and  after  the 
operation. 


OPERATIONS  UNDERTAKEN  FOR  TIfH  RELIEF  oF  CATARACT. 

A  cataract  is  an  opacity  of  the  crystalline  lens,  or  of  its 
capsule,  or  of  both :  the  former  being  much  the  more  common 
variety.  It  may  be  hard,  soft,  or  semili(piid,  and  its  con- 
dition, in  this  respect,  has  an  important  bearing  upon  the 
choice  of  a  method  of  operation.  The  lens  is  composed  of 
a  solid  nucleus  and  a  soft  cortex:  the  whole  lying  free 
within  the  capsule  which   is  itself  attached  to  the  vitreous 

'  Ophtlialiiiic  Ilospital    Roptirts,  \iA.  i.  \k  'I. 
24 


278  OPERATIONS    UPON    THE    EYE. 

huinor.  In  consequence  of  tlie  absence  of  adhesions  between 
the  lens  and  tlie  capsule,  moderate  pressure  is  sufficient  to 
force  out  the  former  after  the  latter  has  been  divided. 

In  operating  u})on  a  cataract,  the  patient  should  be  re- 
cumbent ;  anaesthesia,  though  desirable,  is  not  indispensable, 
except  with  young  children  or  unruly  patients ;  the  other 
eve  should  be  covered  with  a  bandao;e,  unless  its  sight  is 
entirely  lost ;  and  an  eye  speculum  may  be  used  to  keep 
the  lids  apart,  if  the  services  of  a  trained  assistant  cannot 
be  had.  The  objection  to  a  speculum  is  that  it  is  somewhat 
in  the  way  of  the  knife,  cannot  be  removed  promptly  enough, 
and  is  apt  to  make  dangerous  pressure  upon  the  eye.  If 
used,  the  screw  of  the  instrument  should  be  loosened  as  soon 
as  the  incision  has  been  made.  A  few  drops  of  a  solution 
of  atropine  should  be  placed  under  the  lids  a  short  time 
before  the  operation. 

The  methods  of  operation  may  l)e  classified  as: 

Depression  or  couching; 

Division,  discission,  or  solution ; 

Extraction ; 

Operation  for  secondary  cataract. 

Depression  or  coucJiing^  which  was  the  original  and,  for 
many  years,  the  only  method  of  removing  cataract,  is  now 
universally  abandoned,  on  account  of  the  danger  that  the 
displaced  lens  ma}^  set  up  inflammation  of  the  eye  by  con-, 
tact  with  the  other  parts,  especially  the  iris  and  ciliary  pro- 
cesses, and  thus  cause  total  loss  of  sio^ht.  Soelbero-  Wells 
states  that  about  fifty  per  cent  of  the  eyes  thus  operated 
upon  have  been  lost  by  chronic  irido-choroiditis.  The  opera- 
tion will  be  described,  however,  for  the  sake  of  reference. 
If  the  puncture  is  made  in  the  sclerotic,  the  operation  is 
called  sderonyxis  ;  if  in  the  cornea,  kerato7iyxis. 

Scleronyxis. — A  curved  couching  needle  (Fig.  165),  its 
convexity  turned  upward,  is  passed  through  the  sclerotic  on 
the  temporal  side  about  four  millimetres  from  the  margin  of 
the  cornea,  and  three  millimetres  below  the  horizontal  di- 
ameter of  the  eye.  Its  convexity  is  then  turned  forward, 
and  the  needle  cai'ried  behind  and  parallel  to  the  iris,  across 
to  the  upper  and  inner  margin  of  the  pupil  (Fig.  160),  when 
the  handle   is  lightly  tilted  upward,   and   the  lens   slowly 


OPERATIONS   FOR   THK    RKLIKK  UF   CATAKACT.    270 


(Icpivssed  Ijy  the  concave  surface  of  the  necillc.  After  Imhl- 
in»i  it  in  place  for  a  moment,  tlie  nee«lle  is  sliditlv  rotate«l 
to  disentangle  its  point,  and  withdrawn. 

Some  authors  recommend  that  the  anterior 
Fig.  IGo  capsule  shouM  be  formally  divided  horizon- 

tally or  vertically  before  the  lens  is  <le}»ressed. 


u 


\ 


Fig.  166. 


<^ 


^ 


Depressing  cataract. 


Keratonyxis.  —  The     needle     is     passeil 

throuirh  the   cornea   a  little  below  its  hori- 

zontal    diameter,    and   mi<lway  between   its 

centre   and  mar^rin.   and   carried    backward 

|y      and  inward,  through  the  pupil  to  the  lens, 

Couching neetUe.      which  is  then  depressed  as  before. 

In  the  variety  of  depression  called  n'cH- 
nation,  the  upper  e<lge  of  the  lens  is  rotated  backward  about 
its  transverse  axis  at  the  same  time  that  it  is  depressed,  so 
that  its  anterior  becomes  its  superior  surface. 

Division^  Discission,  or  Solution. — The  object  of  this 
operation  is  to  tear  open  the  anterior  capsule  with  a  fine 
needle,  and  by  thus  bringing  the  arjueous  humor  into  con- 
tact with  the  lens  to  promote  the  gradual  softening  and 
absorption  of  the  latter.  The  selection  of  the  term  discis- 
sion was  made  in  consequence  of  an  erroneous  impression, 
that  the  more  completely  the  lens  was  broken  up  at  first, 
the  more  rapidly  would  the  work  of  absorption  go  on,  and 
surgeons,  therefore,  tried  to  cut  the  whole  lens  into  frag- 
ments.  E.xperience  has  since  .<hown  that  in  most  cases  tiie 
absorption  must  be  gradual,  and  the  operation  frequently 


280 


OPERATIONS    Ul'ON    THE    EYE 


Fig.  1(;8. 


repeated,  only  a  small  amount  of  the  substance  of  the  lens 
being  allowed  to  come  into  contact  with  the  aqueous  humor 
on  each  occasion.  If  the  lens  is  all  broken  up  at  once,  the 
numerous  fragments  swell,  and  act  as  foreign  bodies  in  the 
aqueous  humor,  and  set  up  inflammation  in  the  iris  and 
cornea  with  immediate  arrest  of  the  process 
of  absorption.  This  operation  is  more  es- 
pecially indicated  in  the  cortical  cataract  of 
children,  and  of  young  persons  up  to  the 
age  of  twenty  or  twenty-five  years,  also  in 
those  forms  of  lamellar  cataract  in  which 
the  opacity  is  too  extensive  to  allow  of  much 
benefit  being  derived  from  an  artificial  pupil. 
After  the  age  of  thirty-five  or  forty,  absorp- 


FiG.  1G7. 


'/ 


Bowman's  fine 

stop  needle. 


tion  is  much  slower,  and  the  iris  much  more 
irritable. 

There  are  two  methods  of  performing 
the  operation ;  in  one  the  needle  is  passed 
throufrh  the  cornea,  in  the  other  tlirouo-li 
the  sclerotic. 

Division  throiKjli  tin'  Cornea. — The  pupil 
is  widely  dilated  with  atropine,  the  eyelids 
di'awn  apart  by  an  assistant,  or  fixed  with 
the  eye  speculum,  and  a  fold  of  conjunctiva 
on  the  inner  side  of  the  eye  seized  with 
the  fixation  forceps.  A  fine  spear-shaped  needle  with  a 
shoulder  (Fig.  167)  is  passed  through  the  outer  lower  quad- 
rant of  the  cornea,  almost  perpendicularly  to  its  surface  at  a 


Hays's  knife 
needle. 


Ol'EKATlONS    FOR   THK    KEl.lKK   OK   CATARACT       281 

point  ^vell  within  tlic  dilalcd  })U})il,  so  tliat  the  iris  shall  not 
bo  touc-hc'd  l)y  the  needle.  One  or  more  incisions,  accordin;^ 
to  the  effect  desired,  are  then  nuuh'  in  the  anterioi-  capsule 
of  tlie  lens,  the  nee(lle  Avithdrawn,  and  a  compressive  hand- 
age  applied.  The  o])eration  may  he  re))eated  as  soon  as  all 
redness  and  iri'itahility  of  the  eye  have  disappeared. 

Division  tJiroagh  the  Sclerotic  (Hays'). — The  patient 
having  been  prejjared  as  before,  the  knife-needle  (Fig.  1<>!^), 
with  its  cutting  edge  u])ward,  is  passed  through  the  sclerotic 
at  a  point  on  its  transverse  diameter  three  or  four  milli- 
metres from  the  temporal  margin  of  the  cornea,  and  perpen- 
dicularly to  the  surface  «f  the  eyeball.  Its  direction  is  then 
changed  and  its  point  carried  between  the  iris  and  lens  to 
the  opposite  margin  of  the  pupil.  If  it  encounters  and 
penetrates  the  lens  on  the  way,  it  will  prol)ably  dislocate  it, 
in  which  case  extraction  should  be  at  once  performed ;  if 
the  needle  is  pushed  into  the  lens  w^ithout  dislocating  it,  the 
instrument  should  be  withdrawn  until  its  point  is  free,  and 
then  pushed  on  again  in  a  l)etter  direction. 

This  being  accomplished,  the  edge  of  the  knife  is  turned 
back  against  the  centre  of  the  lens,  and  a  free  incision  made 
by  withdrawing  it  a  short  distance,  while  pressing  its  edge 
firmly  against  the  cataract. 

In  order  to  expedite  the  cure,  Wells  thinks  it  is  a  good 
plan  to  combine  division  with  extraction,  and  remove  the 
whole  cataract  by  a  linear  incision  after  it  has  been  softened 
by  contact  with  the  aqueous  humor.  In  children  this  may 
be  done  within  a  week  after  the  division.  The  same  pro- 
ceeding may  be  employed  in  cases  of  partial  cataract,  the 
transparent  portion  of  the  lens  being  made  opaque  and 
softened  by  the  introduction  of  the  needle. 

Extraction. — The  methods  of  extraction  may  be  classified 
as — 

The  flap ; 

Yon  Graefe's; 

The  linear; 

The  scoop; 

Extraction  by  suction;  and 

Removal  of  the  lens  in  its  capsule. 

^  American  Journiil  of  Medical  Sciences,  July,  1855,  p.  81. 

24* 


282 


OPERATIONS    UPON    THE    EYE. 


Fig.  170. 


Flap  Extraction. — The  common  flap  operation  is  cer- 
tainly tlie  best  when  it  is  successful  It  is  nearly  painless, 
does  not  affect  the  appearance  of  the  eye,  and 
leaves  a  natural  movable  pupil.  These  advan- 
tages, however,  are  offset  by  serious  disadvan- 
tages ;  the  great  size  of  the  flap  in\'olves  the 
risk  of  partial  or  difluse  suppuration  of  the 
cornea,  accompanied  possibly  by  suppurative 
iritis  or  irido-choroiditis.  Prolapse  of  the  iris  is 
a  not  unfrequent  complication,  and  the  after- 
treatment  requires  much  more  care  and  atten- 
tion. Many  surgeons  are  unwilling  to  use 
chloroform  in  the  operation,  because  the  wound 
is  so  large  that  a  fit  of  vomiting  may  force  out 
the  vitreous  humor,  or  even  the  retina  and 
choroid. 

The  instruments  required  are  a  Beer's  (Fig. 
152)   or   Sichel's   (Fig.    169)   knife,    fixation 


EiG.  169. 


SichePs  kuife. 


forceps,  Graefe's  cystotome  and  curette  (Fig. 
170),  and  a  small  blunt-pointed  knife  or  pair 
of  scissors  for  enlarging  the  wound,  if  neces- 
sary. 

The  section  may  be  made  in  the  upper  or 
lower  half  of  the  cornea ;  the  former  is  rather 
the  more  advantageous,  the  latter  the  easier  of 
execution. 

Operation.  (Right  eye,  upper  section.) 
First  Stage. — Patient  recumbent,  the  operator 
seated  behind  him.  The  eyelids  are  separated 
by  an  assistant  standing  at  the  patient's  left 
side,  and  drawing  the  lids  gently  apart  with 
the  forefinger  of  each  hand,  without  making 
any    pressure   upon    the    eye.      The 


surgeon 


Von  Graefe's 
cystotome  and 
curette. 


OPERATIONS    FOR   THK    KKI.IKK    OF   CATARACT.    288 

stciidics  tlic  eyc'])all  l)y  piiicliiiiir  up  a.  fold  of  coujuiK'tiva, 
with  fixation  foirc'})s,  cither  just  l)ch)W  tlic  cornea,  as  in  Ki;^;. 
171,  or  bettor,  perhaps,  just  below  its  prolonged  horizontal 
diiuneter  on  the  inner  side,  and  draws  the  eyeball  gently 
down.  He  then  enters  the  point  of  the  knife  at  the  outer 
side  of  the  cornea  half  a  niillinictie  within  its  niarfjin,  and 
just  on  its  transverse  diameter,  and  carries  it  steadily  across 
the  anterior  chandler,  taking  care   to   keep  the  side  of  the 

Fio.   171. 


Flup  f  xtractiou  of  cataract      Mode  of  fixing  tlie  eye  and  making  the  incision. 

blade  parallel  to  the  iris,  and  to  press  slightly  downward 
with  its  back  so  that  it  may  always  fill  the  incision  com- 
pletely and  prevent  the  escape  of  the  a(j[ueous  humor.  The 
counterpuncture  is  made,  by  the  steady  advance  of  the 
knife,  at  a  point  immediately  opposite  that  of  entry,  the 
fixation  forceps  removed,  and  the  knife  pushed  on  in  the 
same  direction  until  the  section  is  all  but  finished  ;  when 
only  a  small  bridge  of  cornea  remains  undivided  at  its  upper 
border,  the  edge  of  the  knife  is  inclined  slightly  forward, 
and  the  section  completed  by  withdrawing  the  knife.  Close 
the  eyelids  for  a  moment  before  beginning  the  second  stage. 
Second  Stage. — The  anterior  capsule  is  next  divided  by 
introducing  the  cystotome  through  the  incision  while  the 
patient  looks  downward,  and  drawing  its  point  gently 
across  that  membrane.     Care  must  be  taken  not  to  displace 


284 


OPERATIONS    UPON    THE    EYE 


the  lens  by  pressing  the  point  too  forcibly  against  it.   Close 
the  eyelids  again  for  a  moment. 

TJdrd  Stage. — The  patient  is  again  directed  to  look  down- 
ward, and  steady  gentle  pressure  is  made  upon  the  eye 
■with  the  forefinger  or  curette  placed  upon  the  lower  lid 
(Fig.  172).  This  pressure  should  first  be  directed  back- 
ward so  as  to  tip  the  upper  edge  of  the  lens  forward,  and 

Fig.  172. 


Flap  extraction  of  cataract.     Removal  of  the  lens  by  pressure. 

then  upward  and  backward  so  as  to  force  the  lens  through 
the  dilated  pupil  into  the  anterior  chamber  and  out  through 
the  incision.  It  should  be  gentle  and  very  steady  so  as  to 
avoid  rupture  of  the  posterior  capsule  and  escape  of  the 
vitreous  humor. 

Any  portions  of  the  cortical  substance  of  the  lens  which 
may  have  been  left  behind  in  the  capsule,  or  stripped  off 
during  the  passage  of  the  lens  through  the  pupil  and  the 
incision,  must  then  be  removed,  and  the  eye  closed. 

Such  was  the  operation  employed  for  extraction  of  the 
ordinary,  hard,  senile  cataract.  The  objections  to  it,  as 
before  mentioned,  were  the  great  size  of  the  flap,  the  pos- 
sible prolapse  of  tlie  iris  during  the  after-treatment,  and 
the  risk  of  iritis  excited  1>y  tlie  bruisini;'  of  the  iris  durins; 
the  passage  of  the  len.'^  through  the  pupil.  Von  (iraefe  was 
the  first  to  suororest  that  this  last  risk  would  be  diminished 
by  the  excision  of  a  portion  of  the  iris,  iridectomy,  and  on 


OP  K  RATIONS   FOR   THK    RELIEF   OF   CATARACT.    285 


putting  the  sii<»;i!;estioii  into  prac-     ^^^'^•■ 
ticc  he  found  that  it  also  enabled  ^ 

liiin  to  remove  the  cataract  safelv 
tlirouijh  a  much  smaller  incision. 
Accordin<^  to  Mr.  Carter,^  A^on 
(Jraete  Avorked  very  sedulously 
during  several  years  at  the  en- 
deavor to  exclude,  one  by  one,  the 
chief  sources  of  the  dangers  ])y 
"which  extraction  was  beset,  and 
he  arrived  at  last  at  the  point  of 
losing  only  four  eyes  out  of  one 
hundred  o})erations.  A  few  im- 
provements in  detail  have  been 
a(Uied  since  his  death,  but  so  far 
as  principles  and  broad  outlines 
are  concerned  he  had  covered  the 
ground.  In  view  of  the  shortness 
of  the  incision,  which  occupies 
not  more  than  one-quarter  of  the 
periphery  of  the  cornea,  the  opera- 
tion is  generally  spoken  of  as  a 
"modified  linear  extraction;"  but 
the  curved  outline  of  the  incision, 
and  the  fact  that  the  lens  is  re- 
moved entire,  certainly  bring  it 
within  the  class  of  flap  extrac- 
tions. 

Von  G-raefes  3Ietliod.  Modi- 
fied Linear^  or  Modified  Flap 
Extraction. — The  instruments  re- 
quired, besides  the  eye  speculum 
and  fixation  forceps,  are  a  long, 
thin,  narrow  knife  (Fig.  17o),  the 
blade  of  which  is  thirty  milli- 
metres long  and  two  millimetres 
wide,  iridectomy  forceps  (Fig. 
174),  scissors,  a  cystotome  (Fig. 
170),  and  a  small  hard-rubber  or 
tortoise-shell  curette. 


Fi(i.  174. 


Wm  Gniefe's 
cataract  knife. 


Iriikctniiiy 
fuiceps. 


1  Hulmes,  Surgery,  its  Principles  and  Practice,  p.  724. 


286  OPERATIONS    UPON     TIIK    EYE. 

The  patient  is  etherized  and  recumbent ;  the  surgeon 
stands  or  sits  behind  him,  holding  the  knife  in  his  right 
hand  for  the  rio-ht  eye,  in  the  left  hand  for  the  left  eve. 
The  eyeball  is  secured  with  the  fixation  forceps,  and  the 
point  of  the  knife  is  entered  in  the  sclerotic  Avith  its  edge 
upward,  one  millimetre  from  the  upper  and  outer  margin  of 
the  cornea,  and  two  millimetres  below  a  tangent  to  its  circle 
drawn  at  the  upper  end  of  its  vertical  diameter  (Fig.  175, 
A).  The  point  of  the  knife  is  at  first  directed  toward  the 
centre  of  the  eyeball,  but  as  soon  as  it  has  penetrated  to  the 
anterior  chamber  it  is  turned  so  as  to  pass  parallel  to  and 
alons  the  anterior  surface  of  the  iris  downward  and  inward 
about  seven  millimetres  to  a  point  corresponding  to  B  m 
Fig.  175.  The  handle  is  then  depressed,  turning  on  the 
back  of  the  blade  in  the  incision,  until  the  point  is  raised  to 
the  horizontal  line  of  the  puncture,  when  the  handle  must 
be  inclined  somewhat  backward,  and  the  point  pushed 
sharply  through  the  sclerotic  and  conjunctiva  at  C,  Fig. 
175.  Great  care  must  be  taken  not  to  make  the  counter- 
puncture  too  far  back  in  the  sclerotic,  a  mistake  which  may 
easily  happen  if  the  blade  is  carried  too  far  downward  and 
inward  before  it  is  turned  up  to  make  the  counter-puncture. 

ViG.  17G. 


Diagram  tu  illustrate  the  lufthod  of  Line  of  Von  Graefe's 

making  Von  Graefe's  incision.  incision. 

The  edge  is  then  directed  forward,  and  the  incision  com- 
pleted by  steady  advance  and  Avithdrawal  of  the  knife. 
The  incision  is  represented  by  the  upper,  undotted  line  in 
Fig.  176  ;  its  centre  should  lie  at  the  junction  of  the  cornea 
and  sclerotic.  The  little  bridge  of  conjunctiva  which  re- 
mains at  the  centre  of  the  incision  is  then  divided  in  such 
manner  as  to  leave  a  conjunctival  flap  two  or  three  milli- 
metres long  adherent  by  its  base  to  the  cornea.     If  the  cata- 


OPERATION'S  FOR  THE  RELIEF  OF  CATARACT   *2S7 

ract  is  hiv^iv  ami  lianl.  it  may  Ik*  a<l\isal)le  to  use  a  hioadcr 
knifl',  aM<l  make  the  points  (»t'  piiiirture  ami  couiiter-puiicture 
one  millimetre  lower,  so  that  it  will  not  be  necessary  to  use 
a  scoop  or  make  miieli  pressure  on  the  eye  to  effect  the 
removal  of  the  lens. 

Manv  sur^reons  prefer  to  make  the  incision  wholly  in  the 
cornea  ancl  close  to  its  euf^e,  on  the  ground  that  the  wound 
will  heal  more  promptly  and  kindly,  and  ])e  accompanied  by 
less  risk  of  loss  of  tlie  vitreous  or  of  prolapse  of  the  iris. 

The  object  of  the  iridertomy^  which  is  the  next  step  in 
the  operation,  is  the  neutralization  of  the  circular  fibres 
rather  than  the  removal,  of  a  large  portion  of  the  iris, 
although  some  surgeons  counsel  the  latter  on  account  of  the 
greater  security  it  gives  against  subsequent  inflammation. 
The  iridectomy  forceps  are  introduced  closed,  and  openetl 
slightly  when  the  point  reaches  the  margin  of  the  pupil. 
The  margin  rises  between  the  branches,  is  seized,  with- 
drawn gently,  and  cut  oft'  with  scissors  close  to  the  forceps. 
If  this  is  properly  done  the  angles  formed  by  the  edges  of 
the  incision  and  the  margin  of  the  pupil  will  appear  in  the 
anterior  chamber  as  at  ^  an<l  B  in  Fig.  177.     The  portion 

Fig.  177. 


Diagrnm  uf  the  correct  and  faulty  sections  of  the  irL>. 


of  iris  removed  should  extend  cpiite  to  its  ciliary  insertion 
so  that  there  may  be  none  to  eng-age  in  the  external  incision 
and  prevent  its  primary  union. 

The  capsule  is  next  freely  divided  by  two  successive 
lacerations  made  with  the  cystotome.  Each  should  begin 
at  the  lower  edge  of  the  pupil  and  extend  upward,  one 
along  the  inner,  the  other  along  the  outer  side,  to  the  uj)per 
border  of  the  lens,  where  it  has  been  exposed  by  the  iridec- 
tomy. This  upper  border  should  also  be  torn  to  an  extent 
corresponding  to  the  external  incision.  This  manoeuvre 
must  be  executed  with  irreat  delicacy  and  li";htness  of  touch, 


288  OPERATIONS    UPON    THE    EYE. 

in  order  tliut  the  lens  may  not  be  displaced  into  the  N'itreous 
humor. 

Tlie  escape  of  the  lens  is  aided  l)y  pressure  upon  the  cor- 
nea with  the  curette.  The  fixation  forceps  are  applied  at 
the  inner  or  outer  side,  and  the  curette  placed  upon  the 
lower  edge  of  the  cornea  and  pressed  sliglitly  l)ackward 
and  upward  so  as  to  cause  the  upper  edge  of  the  lens  to 
present  in  the  section  ;  the  pressure  must  then  be  made 
directly  l)ackward,  in  order  that  the  lens  may  be  rotated 
around  its  transverse  axis  and  tilted  well  forward  into  the 
incision.  The  curette  is  then  pushed  sloAvly  upward  over 
the  surface  of  the  cornea  so  as  to  follow  step  by  step  the 
delivery  of  the  lens.  Any  fragments  scraped  off  during  the 
passage  may  be  removed  by  passing  the  curette  again  over 
the  surfiice  of  the  cornea. 

If  the  vitreous  humor  happens  to  be  liquid  it  may  escape 
as  soon  as  the  first  incision  is  made.  In  such  a  case  it  is 
best  to  excise  a  portion  of  the  iris  and  remove  the  lens  in 
its  capsule  by  passing  a  scoop  beliind  it  into  the  vitreous 
humor  and  lifting  it  out. 

G-ayet  and  Kiiapjys  3Iodification. — Instead  of  lacerating 
the  capsule  as  above  described  these  surgeons  incise  it  with 
a  knife-needle  along  the  line  of  the  corneal  incision.  This 
is  followed  in  tlie  great  majority  of  cases  by  an  unusually 
uneventful  healing  free  from  iritis  and  other  complications, 
but  leaves  the  pupilhiry  area  occupied  by  the  capsule  of  the 
lens.  In  order  to  clear  the  pupil  the  capsule  is  subsequently 
(in  the  third  week  after  the  extraction,  or  later)  split  with 
the  knife-needle,  which  permanently  frees  the  pupil  from 
both  the  anterior  and  posterior  capsules. 

Linear  Extraction.  —  Mr.  Dixon  suo-o-ests^  rectilinear 
extraction  as  a  more  suitable  name,  because  the  incision  in 
the  cornea  is  a  straight  one,  in  contradistinction  to  that  of 
a  flap  extraction  which  also  forms  a  line,  but  a  curved  one. 
This  operation  is  a  modification  of  one  invented  by  Gibson 
in  1811,  which  had  fallen  into  entire  disuse  before  its  rein- 
troduction  by  Von  Graefe  in  1855.  It  is  designed  for  the 
removal  of  soft  cataracts  througli  a  small  corneal  incision, 
especially  the  cortical  cataract  of  individuals  between  ten 

'  Holtnes's  Systom  of  Suro-ei-}',  vol.  iii.  p.  U)*,>, 


OPERATIONS   FOR   THE    RELIEF   OF  CATARACT.    289 

and  tliirty  yeai*s  of  age.  It  is  also  often  employed  with 
advantage  as  supplementary  to  the  needle  operation.  It  is 
perf<>rme<l  as  follows: 

A  straight,  vertical  incision,  from  four  to  six  millimetres 
Ion;:,  is  made  on  the  outer  side  of  the  cornea,  about  two 
millimetres  within  its  margin,  with  a  straight  lance-shape<l 
iridectomy  knife,  which  is  passed  into  the  anterior  chamber 
parallel  to  the  surface  of  the  iris.  The  capsule  is  then  freely 
lacerated  with  the  cystotome,  and  the  esc4ipe  of  the  soft  lens 
facilitated  by  the  introduction  of  a  curette  into  the  wound, 
and  by  making  gentle  pressure  on  the  inner  side  of  the  eye 
with  the  finger.  If  porfions  of  the  cortex  remain  behind 
the  iris  thev  can  be  brou<jht  into  the  anterior  chamber  bv 
closing  the  lids  and  making  gentle  pressure  in  circular  lines 
upon  them.  If  the  iris  protrudes,  it  must  be  gently  replaced, 
or,  if  much  bruised,  excised. 

Scoop  Extraction. — This  is  a  modification  of  linear  ex- 
traction, devised  by  Waldau  to  obviate  the  dangers  and  dif- 
ficulties occasioned  by  the  presence  in  the  lens  of  a  hard 
nucleus  of  greater  or  less  size.  As  the  principal  danger 
ties  in  the  bruising  of  the  iris,  Von  Graefe  met  it  by  iridec- 
lomy,  which  afterward  suggested  to  Waldau  the  idea  of 
introducing  a  scoop  and  removing  the  lens  without  making 
any  pressure  upon  the  eyeball. 

The  instruments  re<juired  are  a  bent  lance-shaped  iridec- 
tomy knife  (Fig.  154),  iridectomy  forceps  and  scissors,  and 
a  thin,  flat,  slightly  concave  scx^op.     Waldau's  scoop  resem- 


FiG.  178. 


Fig.  179. 


Fig.  180. 


C'ritchett's  scoop. 


Bowman's  scoops. 


bled  a  small  spoon.     Three  different    kinds  are  shown  in 
Figs.  178,  179,  ISO. 

The   eye   speculum    and    fixation    forceps   having   been 
applied,  an  incision,  eight  or  nine  millimetres  long,  is  made 

25 


290 


OPERATIONS    UPON    THE    EYE. 


Fig.  181. 


Curette  and  nioutlipiece  for  rcMiinval  nf 
cataract  by  suction. 


at  tlic  Upper  l)or(k'r  of  the  cor- 
nea where  it  joins  the  sclerotic. 
The  corresponding  portion  of 
the  iris  is  removed,  and  the 
capsule  freely  torn  ^vith  the 
cystotome,  as  before  de- 
scribed. 

The  scoop,  with  its  convex- 
ity backward,  is  then  intro- 
duced, and  carried  careftilly 
down  behind  the  lens,  until  its 
extremity  has  passed  the  lower 
margin  of  the  latter,  and  en- 
gaged it  in  its  hook-like  end. 
It  is  then  withdrawn,  care  being 
taken  not  to  press  the  lens 
against  the  iris  and  cornea.  If 
a  little  of  the  vitreous  humor 
escapes  at  the  same  time,  it 
must  be  snipped  off  and  a  com- 
press applied.  It  is  better  to 
remove  any  fragments  of  the 
lens  that  may  be  left  behind  by 
gently  rubbing  the  eyeball, 
rather  than  reintroducing  the 
scoop. 

Removal  hy  Suction. — Lau- 
o-ier  suncrested,  in  1847,  the 
removal  of  soft  cataracts  by  as- 
piration through  a  hollow  nee- 
dle. Blanchet  modified  the 
method  by  substituting  a  small 
canula  for  the  needle,  and  in- 
troducini*;  it  throufrh  an  incision 
in  the  cornea,  but  the  opera- 
tion w^as  not  favorably  received 
until  after  it  had  been  again 
modified  by  T.  Pridgin  Teale, 
Jr.,  in  1863,  who  recommended 
it  as  a  substitute  for  pressure 
in  the  removal  of  the  harder 
portions  of  the  cataract  by  lin- 
ear extraction,  and  as  supple- 


OPERATIONS  FOR  THE  RELIEF  OF  CATARACT.  201 

mentary  to  discission.  The  instruments  re({iiired  are  a 
broad  needle  and  a  suction  curette.  The  hitter  (Fi<j.  181) 
is  descriV)ed  bv  Mr.  Teale^  as  consistinfr  of  three  parts,  a 
curette,  handle,  and  suction  tube.  "The  curette  is  of  the 
size  of  the  ordinary  curette,  but  differs  from  it  in  bein<» 
roofed  in  to  within  one  line  of  its  extremity,  thus  forming  a 
tube  flattened  on  its  upper  surface,  and  terminating,  as  it 
were,  in  a  small  cup.  ' 

The  anterior  cajisule  is  first  ruptured  with  a  fine  needle 
])assed  througli  tlie  cornea,  and  then  an  o)»eninir  is  made 
with  a  broad  needle  in  thy  cornea  tli rough  which  the  curette 
is  passed  to  the  centre  of  the  pupil.  The  soft  matter  is  then 
withdrawn  by  suction. 

Soelberg  Wells"  says  this  operation  has  been  employed  at 
the  Royal  London  Ophthalmic  Hospital  with  great  success, 
and  that  it  is  especially  indicated  in  cases  of  soft  cortical 
cataract.  If  the  cataract  is  somewhat  harder,  it  is  well  to 
break  it  up  with  the  needle  a  few  days  before  attempting  to 
remove  it. 

Removal  of  the  Lens  in  its  Capsule. — This  operation  is 
indicated  when  the  capsule  is  opaque,  and  whenever  the  eye 
is  exceptionally  irritable,  or  has  been  chronically  inflamed, 
so  that  the  accidental  retention  of  any  fragments  of  the  lens 
would  be  a  source  of  serious  danger.  When  successful, 
this  method  o:ives  very  fine  results,  but  its  risks  and  dangers 
are  so  great  that  it  is  seldom  employed.  Originally  intro- 
duced by  Kichter  and  Beer,  it  was  revived  by  Sperino, 
Pagenstecher,  and  Wecker.  The  former  employed  the 
ordinaiy  flap  operation  without  laceration  of  the  capsule. 
Pagenstecher  made  a  large  flap  in  the  sclerotic  together 
with  iridectomy.  Wecker's  method  was  nearly  identical, 
the  incision  being  m.ade  at  the  sclero-corneal  junction. 

Pagenstecher  s  Method. — The  patient  ha^ing  been  thor- 
oughly anesthetized,  a  large  flap  is  made,  usually  down- 
ward, with  a  Beer's  knife,  a  small  l»ridge  of  conjunctiva 
being  left  temporarily  at  its  apex.  Iridectomy  is  then  per- 
formed in  tlie  outer  lower  quadrant,  and  the  conjunctival 

'  Oplithalmic  Hospital  Reports,  vol    iv.  part  '1,  |».  107. 
^  On  the  Diseases  of  the  Eye,  p.  280.     Phila.,  H.  C.  Lea. 


292  OPERATIONS    UPON    THE    EYE. 

bridge  divided  with  blunt-pointed  scissors.  Any  posterior 
synechise  that  may  exist  are  torn  through  with  a  fine  silver 
hook,  and  then  the  lens  removed  in  its  capsule  by  slight 
pressure  upon  the  eyeball.  If  the  hyaloid  membrane  should 
be  ruptured  and  the  vitreous  escape,  the  lens  must  be  re- 
moved with  the  aid  of  a  small  scoop  passed  in  behind  its 
lower  edge. 

Secondary  Cataract. — Secondary  cataracts  vary  much  in 
thickness  and  opacity.  They  may  be  produced  by  portions 
of  the  lens  left  behind  and  becoming  entangled  in  the  cap- 
sule, by  the  deposit  of  lymph  upon  the  latter,  or  by  the 
proliferation  of  the  intracapsular  cells.  No  operation  for 
secondary  cataract  should  be  performed,  until,  at  least, 
three  or  four  months  after  the  removal  of  the  primary  cata- 
ract; and  if  the  pupil  has  become  contracted,  or  if  very 
extensive  posterior  synechiie  have  formed,  a  preliminary 
iridectomy  should  be  made.  Formerly  the  plan  was  to 
remove  the  opaque  and  thickened  membrane  entirely  from 
the  eye,  but  it  has  proved  very  much  safer  and  equally 
efficacious  to  make  a  small  opening  in  the  membrane  with  a 
needle. 

Anaesthesia  is  hardly  necessary.  The  eye  speculum  and 
fixation  forceps  having  been  applied.  Bowman's  fine  needle 
(Fig.  167)  is  passed  through  the  cornea  near  its  margin,  and 
an  effort  made  to  tear  a  hole  with  it  in  the  centre  of  the 
membrane  or  at  the  part  which  is  thinnest  and  least  opaque. 

If  the  membrane  yields  before  the  needle,  or  if  it  is  too 
tough  to  be  torn,  Mr.  Bowman's  device  of  a  second  needle 
must  be  employed.  This  is  to  be  passed  through  the  cornea 
on  the  side  opposite  to  that  occupied  by  the  first  needle, 
and  then  the  operator,  transfixing  and  steadying  the  mem- 
brane with  one  needle,  tears  it  with  the  other.  If  any 
portion  of  the  iris  should  happen  to  be  bruised  or  torn,  it 
must  be  excised  through  a  linear  excision. 

Dr.  Agnew  passes  a  needle  through  the  centre  of  the 
membrane,  thus  steadying  both  it  and  the  eye.  He  then 
makes  a  linear  incision  on  the  temporal  side  of  the  cornea 
through  which  he  passes  a  small  sharp-pointed  hook,  the 
point  of  which  is  passed  into  the  same  opening  in  the  mem- 
brane as  the  needle.     He  next  tears  the  membrane,  rolls  it 


Ol'KKATlON    TO    CORUECT    STRABISMUS.       •2!)3 

up  about  the  hook,  and  citlier  draws  it  out  altoirothci-  or,  if 
tliis  cannot  be  done,  tears  it  Avi(h'Iy  open. 


UI'EHATIOX  TO  CORRECT  STRABISMUS — STRABOTOMY. 

The  tendon  of  the  internal  rectus  is  attached  to  the 
sclerotic  at  a  distance  of  five  millimetres  from  the  border 
of  the  cornea,  tliat  of  the  external  rectus  at  a  distance  of 
seven  millimetres.  Each  tendon  is  seven  or  eight  milli- 
metres broad  and  is  contained  in  a  firm  sheath  resembling 
a  glove  finger,  a  prolongation  or  depression  of  the  capsule 
of  ^Fenon  at  the  point  where  it  is  traversed  by  the  tendon 
about  midway  between  the  anterior  margin  of  the  orbit  and 
the  posterior  pole  of  the  eyeball.  The  capsule  of  Tenon  is 
a  reflection  of  the  periosteum  of  the  orbit  from  the  anterior 
margin  of  the  latter  to  the  transverse  meridian  of  the  eye- 
ball and  thence  backward  to  and  along  the  optic  nerve,  thus 
constituting"  a  diaphragm  Avhich  divides  the  orbit  into  an 
anterior  and  a  posterior  logo,  the  former  of  which  contains 
the  eyeball  (received  into  a  cup-like  depression  of  the 
diaphragm),  the  latter  the  muscles  and  optic  nerve.  The 
capsule  sends  a  prolongation,  not  only  anteriorly  along  the 
tendons,  but  also  posteriorly  along  the  muscles,  and  the 
union  between  the  muscle  and  sheath  is  so  firm  that  even 
after  division  of  the  tendon  the  muscle  can  move  the  eye- 
ball by  acting  through  the  attachments  of  the  capsule.  If 
the  body  of  the  muscle  itself  is  divided  in  the  posterior  lege, 
its  influence  upon  the  movements  of  the  eyeball  is  entirely 
lost.  This  is  the  chief  point  to  be  borne  in  mind  in  per- 
forming strabotomy,  the  tendon  must  be  divided,  not  the 
muscle,  and  the  amount  of  deviation  of  the  eye  to  be  over- 
come is  the  measure  of  the  extent  to  which  the  adjoining 
tissues  must  be  divided. 

The  Operation  for  Division  of  the  Internal  Rectus  will 
alone  be  described,  that  being  the  one  commonly  required. 
The  special  instruments  required  are :  fine-toothed  forceps 
(Fig.  182),  ])lunt  hook  (Fig.  183),  and  blunt-pointed  scissors, 
straight  or  curved  on  the  fiat. 

A  small  but  deep  fold  of  conjunctiva  and  subconjunctival 
tissue   is   seized  Avith    the   toothed   forceps  just  above  the 

2o* 


294: 


OPERATIONS    UPON    THE    EYE. 


lower  extremity  of  the  line  of  insertion  of  the  tendon  of  the 
internal  rectus,  that  is  two  millimetres  below  a  point  on 
the  equator  of  the  eyeball  five  millimetres  beyond  the  inner 
margin  of  the  cornea,  and  divided  with  the  scissors  just 
below  the  forceps ;  additional  snips  are  made  with  the  scis- 
sors within  this  opening  until  the  tendon  or  the  sclerotic  is 
exposed.  The  surgeon  then  passes  the  point  of  the  stra- 
botomy  hook,  which  should  be  somewhat  bulbous,  through 
the  opening  to  the  lower  border  of  the  tendon,  and.  keeping 
the  point  and  side  of  the  hook  constantly  upon  the  sclerotic, 
sweeps  it  at  first  backward,  and  then  upward  and  forward 

Fig.  182. 


Fig.  183. 


=^.^ 


around  the  insertion.  When  this  manoeuvre  is  properly 
executed,  the  point  of  the  hook  can  be  seen  under  the  con- 
junctiva above  the  upper  border  of  the  tendon,  while  its 
course  is  hidden  by  the  latter  and  prevented  from  being 
di'awn  forward  to  the  margin  of  the  cornea.  If  the  whole 
of  the  hook  can  be  seen  under  the  conjunctiva,  it  is  not 
under  the  tendon,  and  the  sweep  must  be  repeated.  When 
the  tendon  has  been  secured,  the  conjunctiva  may  be  pressed 
back  over  its  point,  and  the  tendon  divided  with  scissors  close 
to  its  insertion,  beginning  at  its  upper  border ;  or,  the  con- 
junctiva being  left  in  place,  the  scissors  may  be  passed 
aloncr  the  hook  as  a  ^uide,  one  blade  below  the  tendon,  the 
other  between  it  and  the  conjunctiva,  and  the  tendon  divided 
with  repeated  snips. 

After  the  tendon  has  been  completely  cut  through,  the 
hook  should  be  swept  upward  and  downward  to  ascertain 
if  the  lateral  expansions  of  the  tendon  have  been  divided, 


OPERATION    TO    CORRECT    STRABISMUS.      295 

for  tlie  persistence  of  even  a  few  of  them  might  be  sulficient 
to  })rcveiit  the  i>uccess  of  the  o})eration. 

if  it  is  feared  that  too  great  an  eft'ect  has  ])een  produced, 
a  deep  suture  may  be  passed  through  the  tendon  and  the 
conjunrtiva  on  the  side  toward  tlie  cornea  so  as  to  limit  tlie 
amount  of  retraction.  The  accommodative  movements  (jf 
the  eye  should  be  tested  immediately  after  the  operation, 
and  if  there  is  tlie  slightest  tendency  to  divergence  when 
the  object  is  six  or  eight  inches  distant  from  the  eye  a  sutui'e 
should  ])e  inserted. 

In  the  subconjunctival  method  the  incision  in  the  con- 
junctiva is  made  below  tlie  insertion  of  the  tendon  on  a  line 
with  the  lower  border  of  the  cornea,  and  the  conjunctiva  is 
not  pressed  away  from  the  anterior  surfice  of  the  tendon 
after  the  hook  has  been  passed  under  the  latter. 

If  the  S((uint  exceeds  five  or  six  millimetres,  as  estimated 
by  the  method  shown  in  Fig.  184,  both  eyes  should  be  ope- 


FiG.  184. 


Method  of  estimating  the  degree  of 
squint. 


Double  operation  for  strabismus. 


rated  upon,  the  insertion  of  the  internal  rectus  being  set 
back  in  each  case.  Thus,  if  the  degree  of  squint  repre- 
sented in  Fig.  185  were  corrected  by  setting  back  the 
tendon  of  the  internal  rectus  from  C  to  i>,  the  muscle 
could  only  Avork  at  a  great  disadvantage  as  comjtared  with 
the  internal  rectus  of  the  other  side,  and  the  result  would 
be  the  appearance  of  divergent  squint  whenever  the  attempt 


296  OPERATIONS    UPON    THE    EYE. 

was  made  to  look  at  an  object  near  the  eye,  because  the 
muscle  could  not  turn  the  eye  far  enough  inward.  The 
condition  must  therefore  be  divided  between  the  two  eyes, 
the  internal  rectus  on  one  side  being  set  back  to  E^  on  the 
other  side  to  E' . 

Secondary  Strabismus  foUoiving  Tenotomy  of  the  opjyo- 
nent  is  treated  by  advancing  the  insertion  of  the  tendon  of 
the  latter  [Prorraphy).  Thus,  supposing  divergent  squint 
to  have  followed  division  of  the  internal  rectus,  an  incision 
half  an  inch  long  is  made  in  the  conjunctiva  in  the  line  of 
the  horizontal  diameter  of  the  cornea,  and  the  conjunctiva 
and  subconjunctival  tissue  dissected  up  as  far  back  as  to 
the  caruncle.  A  hook  is  then  passed  around  the  insertion 
of  the  internal  rectus,  and  the  tendon  divided  as  before ; 
a  suture  is  passed  through  it,  and  it  is  drawn  toward,  and 
fastened  to,  the  strip  of  conjunctiva  adjoining  the  inner 
border  of  the  cornea.  The  tendon  of  the  external  rectus 
must  then  be  divided  •  according  to  the  rules  laid  down  for 
division  of  the  internal  rectus,  remembering  that  its  attach- 
ment to  the  sclerotic  is  distant  seven  millimetres  from  the 
edge  of  the  cornea. 


ENUCLEATIOX  OF  THE  EYEBALL. 

As  the  globe  of  the  eye  lies  somewhat  nearer  the  inner 
than  the  outer  side  of  the  orbit,  it  will  be  found  easier  to 
approach  it  from  the  latter  quarter.  Tillaux^  divides  the 
conjunctiva  and  subconjunctival  fascia  with  curved  scissors 
along  the  attachment  of  the  external  rectus,  divides  the 
tendon  of  that  muscle,  carries  the  scissors  backward  through 
the  incision,  their  concavity  turned  toward  the  globe,  and 
cuts  the  optic  nerve  close  to  the  eyeball.  He  then  seizes 
the  posterior  pole  of  the  globe  with  pronged  forceps,  draws 
it  out  through  the  conjunctival  incision,  and  divides  the  re- 
maining conjunctival  attachments  and  tendons  close  to  the 
sclerotic. 

Other  surgeons  prefer  to  seek  and  divide  each  tendon  in 
turn  before  cutting  the  optic  nerve. 

^  Analornie  Topographique,  p.  190. 


OPERATIONS  UPON  LACHRYMAL  APPARATUS.  297 

Extirpation  oftlv  Entire  Contents  >>f  thr  Orbit. — Id  order 
to  gain  iuUlitional  moni,  it  is  well  fii*st  to  divide  the  external 
commissure  of  the  liils.  A  bistoury  is  then  entered  at  the 
inner  angle,  carried  well  back  toward  the  apex  of  the  orbit, 
and  swept  along  the  tlo<»r  tn  the  outer  angle,  then  reintro- 
duced at  the  inner  angle,  and  carried  along  the  roof  of  the 
orbit  to  the  outer  angle.  The  muscles  and  optic  nerve, 
'Ahich  still  remain  attached  to  the  eye  and  apex  of  the  orbit, 
are  finally  divided  with  curved  scissors  introduced  from  the 
outer  side. 

Hemorrhage  should  beaiTested  by  packing  the  cavity  with 
antiseptic  gauze. 


OPERATIONS  UPON  THE  LACHRYMAL  APPARATUS. 

Extirpation  of  the  Lachrymal  Gland  (Fig.  186). — The 
principal  portion  of  the  lachrymal  gland  lies  just  behind  the 


Extirpation  of  the  lachnrmal  gland.  S.  Skin.  P.  Perioetenm.  B.  Frontal  boue.  O. 
Lachrymal  gland.  T.  Capbule  of  Tenon.  B.  Eeflected  periostenm  forming  the  capsule 
of  the  gland.     E.  Ereball.     C.  Conjunctiva.     L.  Eyelid.     /.  Incision. 

junction  of  the  upper  and  outer  margins  of  the  orbit,  envel- 
oped in  a  fibrous  capsule  fonned  by  a  reflection  of  the  peri- 
osteum or  capsule  of  Tenon.  The  '*  accessory"  portion,  to- 
gether with  the  ducts,  occupies  the  adjoining  eyelid,  and  is 
compose(^l  of  isolated  granulations  of  glandular  tissue,  which. 


298  OPERATIONS    UPON    THE    EYE. 

if  left  behind  after  removal  of  the  main  portion,  may  con- 
tinue to  secrete  tears  and  discharge  them  into  the  wound, 
thus  causing  abscesses  and  fistulse. 

Tillaux^  has  pointed  out  that  the  existence  of  the  fibrous 
capsule  renders  it  possible  to  enucleate  the  gland  without 
opening  the  posterior  loge  of  the  orbit,  a  defect  in  the  older 
methods  which  included  division  of  the  external  commissure. 
Make  an  incision  one  inch  in  length  along  the  upper  and 
outer  portion  of  the  bony  margin  of  the  orbit.  Carry 
this  incision  through  all  the  soft  parts,  including  the  perios- 
teum, down  to  the  bone ;  separate  the  periosteum  from  the 
bone  at  the  under  side  of  the  incision,  and  depress  it.  The 
gland  can  then  be  distinctly  seen  through  the  thin  layer  of 
periosteum  which  separates  it  from  the  roof  of  the  orbit,  and 
can  be  removed  with  sjreat  ease  after  the  latter  has  been  torn 
through. 

Lachrymal  Sac^  Duct^  and  CanalicuU. — The  lower  cana- 
liculus passes  dowmward  from  the  punctum  for  two  milli- 
metres, then  turns  at  a  right  angle,  and  passes  horizontally 
inward  to  the  lachrymal  sac,  a  distance  of  about  five  milli- 
metres ;  the  upper  canaliculus  passes  at  first  upward  for  two 
millimetres,  and  then  downward  and  inward  to  the  sac.  This 
sharp  turn  in  the  course  of  the  canaliculus,  which  is  an 
obstacle  to  catheterization,  can  be  temporarily  removed  by 
drawing  the  border  of  the  lid  outward.  The  lachrymal 
sac  lies  just  behind  the  tendo  oculi,  and  receives  the  cana- 
liculi  by  a  common  duct  two  or  three  millimetres  below  its 
upper  extremity,  their  relations  thus  resembling  those  of  the 
ilium  and  caecum,  a  resemblance  which  is  increased  by  the 
presence  of  a  valve  at  the  opening  of  the  duct  into  the  sac. 
This  valve,  described  by  Huschka,  is  thought  to  prevent  the 
reflux  of  the  contents  of  the  sac  into  the  canaliculi.  The 
direction  of  the  sac  is  downward  and  backward  at  an  angle 
of  45°  ;  it  occupies  the  lachrymal  groove,  which  is  bounded 
anteriorly  by  a  ridge  on  the  nasal  process  of  the  superior 
maxillary  bone  at  the  inner  angle  of  the  orbit,  and  is  crossed 
by  the  tendo  oculi  just  at  the  juncti(m  of  its  upper  and 
middle  thirds.      The  nasal  duct  is  the  direct  continuation  of 

'  Anatomic  Topographique,  p.  237. 


OPERATIONS   U  P  O  N    L  A  C  II  P.  Y  M  A  L   A  P  1'  A  R  A  T  U  S  .     200 


the  sac,  ami  j)as,<es  dowinvartl, 
backward,  ;nnl  oiitwanl ;  tlic 
coni))im'4  lou^itli  <jf  the  (hict 
and  sac  is  about  one  incli. 

It  niav  l)ec-ome  necessary  to 
slit  up  the  rayviliiidus  in  order 
to  correct  a  malposition  of  tlie 
punctum,  or  to  facilitate  cathe- 
terization of  the  sac  and  nasal 
duct.  This  little  operation  is 
best  performed  as  follows  (right 
eye,   lower  lid):     The 


Fig.  iHh. 


surgeon 


stands  behind  the  patient,  who 
is  recumbent,  and  introduces  a 
fine  grooved  director  (Fig.  187) 
vertically  through  the  punctum 
for  a  distance  of  two  millimetres. 
Then  drawing  the  border  of  the 
lid  outward  and  somewhat  down- 
ward with  the  forefinger  of  his 
left  hand,  he  passes  the  director 
horizontally,  with  its  groove  up- 
ward, along  the  canaliculus  to 
the  inner  side  of  the  sac.  Then, 
shifting  the  director  to  the  left 
hand,  he  engages  a  sharp-pointed 
knife  in  the  groove,  and  slits  up 
the  canaliculus  throughout  its 
entire  lenorth. 

Bowman's  probe-pointed  ca- 
naliculus knife  (Fig.  188)  may 
be  substituted  for  the  director 
and  knife.  It  should  be  very 
narrow,  and  its  probe  point  very 
small. 

When  one  punctum  has  been 
entirely  obliterated,  a  plan  sug- 
gested by  Mr.  Streatfeild  may 
be  employed.  He  divides  the 
other  canaliculus,  passes  a  fine 
director,  suitably  bent,  through 


\ 


Fig.  187. 


A 


Sharp  pointed 
canaliculus  di- 
rector. 


Bowman's  probe- 
pointed  canaliculus 
knife. 


300 


OPERATIONS    UPON    THE    EYE. 


the  wound  into  the  obliterated  canalicukis  and  cuts  down 
upon  it. 

If  the  divided  lower  canaliculus  remains  everted,  Mr. 
Critchett  advises  that  the  posterior  lip  of  the  incision  be  cut 
off  with  scissors,  "  effecting  the  treble  object  of  drawing  the 
canal  further  inward,  of  forming  a  reservoir  into  which  the 
tears  may  run.  and  of  preventing  reunion  of  the  parts." 

Puncture  of  the  Sac  (Fig.  189). — The  three  guides  are 
the  tendo  oculi,  the  anterior  margin  of  the  lachrymal  groove, 

Fig.  189. 


PuiiL-ture  of  the  lacbryiual  sac. 


and  the  direction  of  the  sac.  While  an  assistant  draws  the 
external  commissure  outward,  so  as  to  make  the  tendo  oculi 
tense  and  plainly  visible,  the  surgeon  places  his  left  fore- 
finger upon  the  inner  and  lower  margin  of  the  orbit,  so  as  to 
have  the  bony  edge  between  the  nail  and  the  pulp  of  the 
finger,  and  holding  the  knife  in  the  direction  of  the  canal, 
that  is,  nearly  parallel  to  the  median  plane,  and  at  an  angle 
of  45°  with  the  horizon,  he  passes  it  along  his  finger-nail 
into  the  sac  just  below  the  tendon.  It  is  important  to  mark 
the  position  of  the  anterior  margin  of  the  canal,  so  as  to 
avoid  the  not  infrequent  mistake  of  passing  the  knife  en- 
tirely outside  of  the  orbit  between  the  soft  parts  of  the  face 
and  the  bone. 


OCCLUSION   OF   EXTERNAL   AUDITOKY    CANAL.    :>01 

Stricture  of  the  Xasul  -Duct,  [tiviston. — Dr.  Stillinir, 
of  Ciissol,  pmposes  to  treat  stric-tiiiv  of  tlic  nasal  diict  by 
internal  tlivision.      He  divides  the  eanaliculii<.   .ind    .iscor- 

Fio.  ir<n 


Stilling's  knife. 


tiiin.s  the  seat  of  the  stricture  with  a  prohe,  pas.«?es  his  knife 
(Fig.  lOO)  through  it,  and  divides  it  in  three  or  four 
direction."?. 


CHAPTER  II. 

OPERATIONS  UPON  THE  EAR  AND  ITS  APPENDAtiES. 
OCCLUSION  OF  EXTERNAL  AUDITORY  CANAL. 

Congenital  occlusion  of  the  external  meatus  is  usually 
associated  with  absence  or  defective  development  of  the 
other  portions  of  the  au<litory  apparatus.  Before  operating 
upon  such  an  occlusion,  therefore,  the  hearing  power  should 
be  tested,  and  the  permeability  or  impermeability  of  the 
bony  portion  of  the  canal  determined  by  jiuncture  with  a 
needle. 

If  the  occlusion  consists  of  a  simple  membranous  dia- 
phragm it  should  be  divided  crucially,  and  the  flaps  excised. 
For  deeper  and  more  extensive  obstructions  cauterization 
with  nitrate  of  silver  is  to  be  preferred. 

INTRODUCTION  OF  SPECULUM  (rooSa). 

The  upper  portion  of  the  auricle  is  grasped  between  the 
ring  and  middle  fingers  of  the  left  hand  and  drawn  gently 
upward  and  backward.  Into  the  canal  thus  straightened 
the  speculum  is  introduced  with  the  right  hand,  and  then 
held  in  place  with  the  thumb  and  forefinger  of  the  left,  the 

26 


302  OPERATIONS    UPON    THE    EAR. 

hand  beino;  steadied  1)y  restiiijx  its  ulnar  border  against  the 
patient's  head.  Complete  control  of  the  speculum  is  thus 
obtained,  and  it  can  be  easily  moved  about  so  as  to  bring 
every  i)art  of  the  tympanum  and  canal  into  view.  Light 
should  be  thrown  into  it  from  a  concave  mirror  perforated 
in  the  centre  and  having  a  focal  distance  of  six  inches. 


PARACENTESIS  OF  THE  MEMBRANA  TYMPANI  (rOOSA).^ 

This  should  be  performed  while  the  head  of  the  patient 
is  well  supported  and  a  good  light  is  thrown  upon  the  mem- 
l)rane  by  a  mirror  attache<l  to  a  forehead  band.  A  cataract 
needle  is  the  instrument  usually  emplo^^ed,  and  the  opening 
should  be  made  in  the  posterior  inferior  quadrant  of  the 
membrane. 

Tillaux-  calls  attention  to  the  fact  that  all  the  important 
elements  of  the  membrane  occupy  its  upper  half,  and  that 
an  incision  or  rupture  near  the  handle  of  the  hammer  may 
give  rise  to  troublesome  and  even  dangerous  hemorrhage. 
The  lower  half  is  less  vascular  and  less  sensitive. 

If  it  is  desired  to  maintain  the  opening  for  several  days, 
a  crucial  incision  may  be  made,  or  a  triangular  flap  excised, 
but,  as  a  rule,  even  these  incisions  heal  very  quickly. 


INCISION  OF  THE   PERIOSTEUM  AND  OPENING  OF  THE 
MASTOID  PROCESS. 

When  the  periosteum  of  the  mastoid  process  has  become 
inflamed  by  propagation  of  an  inflammatory  process  either 
from  the  periosteum  of  the  auditory  canal  with  which  it  is 
continuous,  or  from  the  cavity  of  the  tympanum  through 
the  mastoid  cells,  an  early  and  free  incision  down  to  the 
bone  will  give  great  relief  and  diminish  the  danger  of  in- 
tracranial  complications.  The  incision  should  begin  a  little 
above  the  apex  of  the  mastoid  process,  and  be  carried  up- 
ward for  an  inch  or  an  inch  and  a  half  parallel  to  the  at- 
tachment of  the  ear  and  about  half  an  inch  from  it.     The 

'  TreatUe  on  the  Diseases  of  the  Ear,  p.  246. 
2  Anatomic  Topographique,  p.  111. 


CATHETERIZATION    OK    EUSTACHIAN    TU1{E.:303 

posterior  amic-iilar  artery  lies  in  tlie  "j^roove  between  tlie  ear 
and  the  mastoid  })rocess,  and  will  not  be  encountered  ;  its 
posterior  branch,  however,  the  course  of  which  is  uncertain, 
will  probably  be  divided  and  may  give  rise  to  troublesome 
hemorrhage.  The  artery  is  so  adherent  to  the  skin  that  it 
cannot  be  readily  tied  or  twisted.  If  ordinary  pressure 
does  not  suffice,  self-retaining  forceps  should  be  apj)lied  to 
the  bleeding  point,  and  left  in  place  for  twenty-four  hours. 

The  chisel,  which  should  be  only  one-eighth  inch  wide, 
should  be  apj)lied  close  behind  the  insertion  of  the  auricle  on 
a  level  with  the  upper  wall  of  the  meatus,  at  a  shallow  de- 
])ression,  known  as  DesiHvnne's  pit,  and  the  cutting  should 
be  done  iuAvard  and  forward,  parallel  to  the  meatus.  The 
proximity  of  the  lateral  sinus  must  be  borne  in  mind. 

CATHETERIZATION  OF  THE  EUSTACHIAN  TUBE. 

The  Eustachian  tube  is  from  one  and  a  half  to  two  inches 
long,  its  course  is  from  the  pharynx  upward,  backward,  and 
outward.  Its  pharyngeal  orifice  is  oval  and  well  marked 
except  on  the  lower  border,  and  is  situated  just  above  the 
base  of  the  soft  palate.  Behind  the  orifice,  between  it  and 
the  posterior  wall  of  the  pharynx,  is  a  depression  (Rosen- 
mliller's  fossette)  in  which  the  beak  of  the  catheter,  if 
carried  too  far  back,  may  lodge  and  give  the  same  sensa- 
tion to  the  suro-eon's  hand  as  if  it  were  eno;ao;ed  in  the  tube. 
Of  the  two  mistakes  most  frequently  made  in  performing 
catheterization,  one  is  to  pass  the  beak  of  the  instrument 
between  the  middle  and  inferior  turbinated  bones  instead  of 
along  the  floor  of  the  nasal  fossa,  and  the  other  is  to  mistake 
Rosenmliller's  fossette  for  the  orifice.  According  to  Roosa,^ 
the  first  mistake  is  best  avoided  by  drawing  down  the 
patient's  upper  lip  with  the  left  hand,  and  entering  the 
catheter  while  it  is  held  in  an  almost  vertical  position,  its 
concavity  directed  toward  the  median  line.  After  the 
beak  has  fairly  entered  the  meatus  the  stem  of  the  catheter 
is  gradually  raised  to  the  horizontal  position  and  passed 
backward,  its  beak  resting  (►n  the  floor  of  the  meatus  close 
to  the  septum,  its  convexity  u})ward. 

^  Diseases  of  the  Ear,  p.  '.>1. 


304      OPERATIONS  UPON   MOUTH   AND   PHARYNX. 

Tillaux^  ogives  the  followiiior  directions  for  findiiif]^  the 
orifice :  1st.  Carry  the  catheter  directly  backward,  its  con- 
cavity dowmvard,  until  it  touches  the  posterior  wall  of  the 
pharynx.  2d.  Withdraw  it  until  the  beak  rests  again  upon 
the  hard  palate.  3d.  Carry  the  catheter  again  very  gently 
backward,  and  feel  with  its  beak  for  the  posterior  border  of 
the  palatine  aponeurosis,  the  firm  fibrous  continuation  of  the 
palatal  bone.  This  aponeurosis  feels  as  hard  as  bone,  and 
its  posterior  border  can  be  easily  recognized  by  the  softness 
of  the  adioininor  tissues.  4th.  Rotate  the  beak  of  the 
catheter  outAvard  and  upward,  and  it  will  enter  the  Eusta- 
chian tube. 


CHAPTER   III. 

OPERATIONS  UPON  THE  MOUTH  AND  PHARYNX. 


EXCISION  OF  THE  TONSILS  (aMYGDALuTOMY). 

The  tonsils  may  be  excised  with  a  knife  and  vulsellum,  or 
with  a  specially  contrived  instrument,  the  tonsilotome  or 
guillotine. 

Anaesthesia  is  not  required.  If  the  patient  is  young  or 
nervous  it  is  well  to  put  a  large  piece  of  cork  between  the 

Fig.  191. 


G.  T/EMA  NN  &.  C  o7~^^^^% 
Tonsilotome. 


jaws  on  each  side  to  prevent  the  mouth  from  being  closed. 
The  tonsilotome  (Fig.  191)  is  composed  of  two  rings  and  a 
fork  mounted  upon  stems  so  arranged  that  they  can  be 
worked  with  the  thumb  and  fingers  of  one  hand.  The  two 
rings  slide  flatwise  upon  each  other,  and  the  inner  edge  of 

^  Anatomie  Topograpbique,  ji.  140. 


STAPHYLORAPHY.  305 

one  is  sharp,  so  tliat  when  <lrawn  across  the  other  it  divides 
anything  l}'i";x  within  it.  The  fork  is  thrust  forwanl 
across  the  rin^  and  drawn  awav  vertically  from  it  bv  the 
same  movement  which  ch'aws  one  ring  across  the  otlier.  The 
rings  having  been  i)la(ed  over  the  tonsil,  the  hook  is  driven 
into  the  latter  by  a  ([uick  movement  of  the  thumb  and  finger 
and  draws  it  further  into  the  ring,  holding  it  tense  a.s  the 
other  blade  cuts  across  its  base.     The  pain  is  very  slight. 

If  the  tonsilotome  cannot  be  used  the  tonsil  must  be  seized 
with  pronged  forceps,  and  excised  between  them  and  the 
pillars  with  a  probe-pointed  knife,  the  posterior  portion  of 
the  blade  being  guarded  with  diachylon  plaster  so  as  to 
avoid  injury  to  the  tongue. 


STAPHYLORAPHY. 

At  the  conclusion  of  his  historical  account  of  this  opera- 
tion YerneuiP  states  that  it  has  been  invented  foui*  different 
times.  The  earliest  record  of  the  operation  is  found  in  a 
French  book  published  in  ITGG,-  in  which  it  is  said  that  a 
dentist,  named  Lemonnier,  closed  a  fissure  of  both  hard  and 
soft  palates  bv  freshen  in  cf  its  ed^es  with  a  knife  and  brinofinor 
them  together  with  sutures.  He  also  closed  perforations  of 
the  hard  palate  by  exciting  suppuration  of  their  borders. 

In  1799  Eustache.  a  physician  of  Beziers.  proposed  to 
reunite  bv  sutures  the  edges  of  an  incision  which  he  had 
made  the  day  before  in  the  soft  palate  of  a  patient  for  the 
pui'pose  of  removing  a  pharyngeal  polyp.  The  patient  re- 
fused the  operation.  Four  yeai's  later,  in  1803,  Eustache 
sent  to  the  Academic  Rovale  de  Chirurfrie  at  Paris  a  remark- 
able  paper  upon  congenital  fissures  in  the  soft  palate,  and 
asked  the  Society's  approval  of  the  operation  by  which  he 
proposed  to  close  them.  The  approval  was  withheld,  and 
there  is  no  record  of  any  further  steps  having  been  taken. 

In  December,  1816,  Von  Graefe  said,  before  the  Medico- 
Chirurgical  Society  of  Berlin,  that,  after  many  unsuccessful 
attempts  to  close  fissures  of  the  soft  palate,  he  had  at  last 

^  Cbirurgie  Reparatrice,  1877.     Art.  Staphylorrhapbie. 
*  Traits  des  Principaux  objets  de  Medecine,  par  Robert. 

26* 


306      OPERATIONS   UPON   MOUTH   AND   PHARYNX. 

succeeded  bv  di-awinoj  the  edores  too:ether  ^vith  sutures  after 
freshening  them  by  applying  muriatic  acid  and  the  tincture 
of  cantharides.  This  remark  was  reported  in  the  proceed- 
insfs  of  the  Society  in  Huf eland' s  Journal^  January,  1817. 
Between  1816  and  1820  Von  Graefe  repeated  the  operation 
three  times,  each  time  without  success. 

In  1819,  Roux.  apparently  in  entire  ignorance  of  Yon 
Graefe' s  attempt,  closed  a  fissure  by  paring  the  edges  and 
applying  sutures.  The  case  at  once  became  yery  widely 
known,  and  had  much  influence  in  popularizing  the  opera- 
tion. 

When  the  extent  of  tlie  lesion  which  staphyloraphy  is 
designed  to  repair  is  considered,  the  operation  seems  to  be 
yery  simple.  It  is  only  necessary  to  freshen  the  edges  of 
the  gap  and  draw  them  together  with  sutures.  Practically, 
howeyer,  the  operation  is  a  difficult  one :  the  parts  lie  at  a 
considerable  distance  from  the  sui'face,  the  manipulations 
are  constantly  interfered  with  by  inyoluntary  moyements 
of  deo:lutition,  the  flow  of  blood  increases  the  obscurity, 
and  the  practical  difiiculties  in  the  way  of  placing  the 
sutures  are  great.  Finally,  unless  some  of  the  muscles  of 
the  palate  are  diyided,  the  tension  exerted  by  them  upon 
the  sutures  is  sufiicient  to  prpyent  union. 

A  ofreat  yariety  of  methods  have  been  suscrested  to  over- 
come  these  difficulties.  Mr.  T.  Smith  diminished  the  first 
by  the  inyention  of  a  gag  (Fig.  192),  designed  to  hold  the 
jaws  apart  during  the  operation.  Prof  Van  Buren  pre- 
yented  the  passage  of  blood  into  the  trachea  during  the 
employment  of  aniesthesia  by  placing  the  patient  so  that 
the  head  should  hang  down  oyer  the  end  of  the  table,  and 
the  blood  escape  through  the  nose.  The  same  device  has 
been  recently  employed  by  Trelat. 

Sir  William  Fergusson  relieved  the  tension  by  dividing 
the  levator  palati  on  each  side.  He  did  this  by  passing  a 
knife,  bent  at  a  right  angle,  through  the  cleft  and  dividing 
the  muscle  from  behind  forward,  without  touching  the  mu- 
cous membrane  on  the  anterior  face  of  the  palate.  The 
incision  should  be  perpendicular  to  the  centre  of  a  line 
joining  the  hamular  jprocess  and  the  orifice  of  the  Eusta- 
chian tube.  The  former  can  be  readily  felt  just  behind  the 
last  upper  molar  tooth,  the  latter  can  usually  be  seen  through 


STAPHYLORAFH Y 


:]07 


the  cleft  in  the  palate.     He  als«»  recomiiien(le<l  division  of 
the  palato-phai yntreii.s  muscle. 

Sedillot'  divideil  the  muscle  from  before  backward.      He 
drew  the  velum  downward  and  inward  with  pronged  forceps. 


Fig.  192. 


Whitebead'o  modificatioD  of  Smith's  gag. 


and  made  an  incision  downward  and  outward  about  one 
centimetre  above  and  <«n  the  outer  side  of  the  base  of  the 
uvula,  and  just  behind  and  on  the  inner  side  of  the  last 
upper  molar,  crossing  the  levator  palati  at  right  angles 
(Fig.  194).  A  length  of  one  centimetre  is  usually  suffi- 
cient, but  it  must  be  increased  if  the  muscular  contractions 
persist.  The  relaxation  of  the  parts  produced  by  these  in- 
cisions is  shown  bv  a  comparison  of  Figs.  193  and  195. 
Unless  the  incisions  are  exceptionally  large  their  sides  re- 
main in  contact ;  in  any  case  they  promptly  reunite.  He 
then  divided  the  anterior  and  posterior  pillars,  seizing  each 
in  turn  near  its  centre  with  pronged  forceps,  and  cutting  it 
with  scissors. 

Mr.  George  Pollock-  has  modified  this  slightly  by  making 

'  Medecine  Op^ratoire,  vol.  ii.  p.  65. 

2  Holmes's  System  of  Surgery,  vol.  iv.  p.  426. 


308      OPERATIONS  UPON   MOUTH   AND  PHARYNX. 

tlie  incision  on  the  anterior  surface  of  the  palate  smaller. 
One  of  the  halves  of  the  palate  is  drawn  toward  the  median 
line  by  means  of  a  ligature  passed  through  it  near  the  base 
of  the  uvula,  and  a  thin,  narrow  knife  is  entered  close  to 
the  hamiilar  process,  a  little  in  front  of  it  and  on  its  inner 
side,  and  its  point  carried   upward,  backward,   and    some- 


FiG.  193. 


Fig.  Ut4. 


Fig.  105. 


what  inward,  until  it  can  be  seen  through  the  cleft,  having 
divided  on  its  way  part,  if  not  all,  of  the  tendon  of  the 
tensor  palati.  The  blade  now  lies  above  most  of  the  fibres 
of  the  levator  (Fig.  196),  and  by  raising  the  handle  and 
cutting  downward,  as  the  knife  is  withdrawn,  an  incision  of 
considerable  length,  including  the  greater  portion  of  the 
levator,  is  made  on  the  posterior  surface  of  the  palate,  while 
that  on  the  anterior  surfiice  need  not  be  greater  than  the 
breadth  of  the  knife.  If  the  muscle  has  been  eftectually 
divided  the  palate  will  be  pendulous  and  flaccid,  and  will 
not  contract  spasmodically  when  pulled  upon.  If  any  re- 
sistance should  persist  the  knife  must  be  introduced  again 
through  the  wound  and  the  incision  enlarged  downward. 

Roux  placed  his  sutures  by  putting  a  needle  at  each  end 
of  the  thread,  and  passing  them  from  behind  forward. 
Trelat  used  a  needle  fixed  upon  a  long  handle,  the  point 
bearing  the  eye  and  curved  in  the  form  of  a  U.  After 
having  been  threaded  the  point  of  the  needle  was  j^assed 
through  the  palate  from  behind  forward,  the  thread  was 
drawn  through  with  a  ho(>k  or  forceps,  and  the  needle,  still 


STATU  YLORAIMI  Y. 


;509 


tliroiuU'd,  witlidruwii  and  passed  in  tlie  same  manner  on  tlio 
opposite  side.  Tlie  objection  to  tliesc  and  to  uU  otlier 
methods  in  wliieli  the  needle  is  passed  from  l)eliind  forward, 
is  that,  since  the   point  cannot  l)e  seen,  it  is  very  difrieult  to 


Fio.  Um;. 


J>ivisii)|i  nf  iiiiiricli'S  of  soft   piilah', 

make  the  punctures  on  one  side  correspond  properly  with 
those  on  the  other.  If  silk  sutures  are  used  each  end  may 
be  passed  from  before  backward,  the  two  tied  together 
loosely,  an<l  tlie  knot  ])ulled  back  througli  one  of  tlie  punc- 
tures, tlius  })ringin!j:  the  lo(jp  l)eliind  tlie  ])alate. 

The  method  now  usually  employed  is  the  one  introduced 
by  Berard.  A  curved  needle  fixed  on  a  Iouli;  handle  is 
threaded  with  a  ligature  three  feet  long,  and  its  point  passed 


310      OPERATIONS  UPON   MOUTH   AND  PHARYNX. 

tliroiigli  the  palate  from  before  backward ;  the  thread  is 
caught  with  hook  or  forceps  on  the  posterior  side,  and  its 
end  drawn  out  through  the  mouth,  the  needle  is  then  with- 
drawn and  slipped  off  the  thread.  It  is  next  threaded  with 
a  second  ligature  and  passed  in  the  same  manner  through 
the  opposite  half  of  the  palate,  the  loop  seized  as  before, 
drawn  through  a  short  distance,  and  held  while  the  needle 
is  withdrawn,  leaving  the  thread  double  in  the  puncture — the 
loop  behind  the  palate,  the  two  ends  in  front.  The  poste- 
rior end  of  the  first  ligature  is  then  passed  through  the  loop 
of  the  second  one  (Fig.  197,  h),  and,  by  the  withdrawal  of 


Fig.  197. 


Staphj'lyraphj- ;  passing  the  sutures. 


the  latter,  drawn  through  the  second  puncture  (Fig.  1*JT,  a). 
Instead  of  using  the  same  needle  to  pass  both  ligatures,  it  is 
more  convenient  to  have  two  curved  spirally  in  the  opposite 
directions,  one  for  each  side. 

If  silver  sutures  are  used,  thread  loops  should  be  passed 
from  before  backward  on  each  side,  one  end  of  the  wire  en- 
ffaojed  in  each  and  drawn  throu«i-li. 

After  a  suture  has  been  passed,  the  ends  should  be 
brouo;ht  out  through  the  mouth,  and  tied  tofjether  for 
safety.  AVlien  all  have  been  passed,  the  anterior  one  is 
drawn  u|»on  to  l)ring  tlie  edges  of  the  cleft  together,  and 
tlie  knot  tied.     The  knot  may  be  an  ordinary  square  one. 


STAPH  YLOR  A  IMiy.  311 

an  jussistant  lioMin^  the  first  twist  witli  drcssin;^  forcejis 
until  tlie  second  is  made,  or  it  may  be  a  noose,  Jis  shown  in 
Fi*T".  ll^T,  '',  seeured  hy  a  second  knot.  If  silver  wire  is 
used,  it  may  be  fastened  by  twisting  it,  or  by  elainping  a 
small  lead  button  upon  it.  Verneuil  fii-st  passes  the  ends  of 
the  wire  thron<rli  the  eves  of  a  shirt  button,  and  then  ties  or 
twists.  He  thinks  this  favors  more  accurate  adjustment  of 
the  edges,  and  facilitates  removal  of  the  wire. 

The  edges  of  the  cleft  are  pared  by  seizing  the  tip  of  the 
uvula  with  toothed  forceps,  making  it  tense,  entering  the 
point  of  a  narrow-bladed  knife  one  or  two  millimetres  back 
from  the  edge,  and  cutting  down  to  the  tip;  then  turning 
the  knife  and  cutting  up  to  the  anterior  angle  of  the  cleft. 
Care  should  be  taken  to  do  this  thoroucrhlv.  When  the  cleft 
is  very  short  (bifid  uvula),  Nelaton  employed  the  method 
alreaiiy  described  under  his  name  for  single  uncomplicated 
harelip.  The  flaps  were  left  adherent  to  each  other  at  the 
apex  (angle  of  the  cleft)  and  to  the  uvula  at  their  bases, 
turned  down,  and  the  raw  surfaces  drawn  together.  When 
the  cleft  was  too  long  for  this  he  separated  the  flaps  at  the 
apex,  shortened  them  by  trimming  off  the  free  ends,  turned 
them  down,  and  united  as  before. 

There  is  no  settled  rule  of  practice  establishing  the  order 
in  which  the  different  steps  of  the  operation  shall  be  exe- 
cuted, except  that  most  surgeons  are  agreed  upon  the  ad- 
visability of  paring  the  edges  of  the  cleft  before  passing  the 
sutures.  Mr.  Callender  recommended  that  the  muscles 
should  be  divided  a  day  or  two  before  the  attempt  to  close 
the  cleft,  on  the  ground  that  the  second  operation  is  much  sim- 
plifie<I  by  the  freedom  from  the  bleeding  occasioned  by  divi- 
sion of  the  muscles.  Mr.  Smith,  on  the  other  hand,  stretched 
the  palate  by  drawing  upon  all  the  sutures,  divided  the 
palato-pharyngeus  and  levator  palati,  and  then,  if  the  edges 
of  the  cleft  did  not  come  easily  together,  made  two  lateral 
oblique  cuts,  one  on  either  side,  above  the  higher  suture, 
separating,  to  a  limited  extent,  the  soft  from  the  margin  of 
the  hard  palate. 

Bonfils,  according  to  Dubrueil.  closed  an  opening  lef^  at 
the  upper  part  of  the  palate  by  the  partial  failure  of  an 
operation  for  stapliyloraphy,  by  taking  a  flap  from  the  hard 
palate,  according  to  the  Indian  method  of  autoplasty  [q.  v.). 


312      OPERATIONS  UPON   MOUTH   AND  PHARYNX. 


URANOPLASTY. 

VerneuiP  attributes  tlie  success  of  modern  uranoplastic 
operations  to  the  use  of  the  method  by  (h>uble  flaps,  adherent 
at  both  ends  and  bronglit  together  hiterally  (liimleaux  en 
■pont),  and  to  the  retention  of  the  periosteum  in  the  flaps. 
He  ascribes  the  first  use  of  double  flaps  to  Dieflenbach,  and 
thinks  the  retention  of  the  periosteum  was  brought  about  by 
Ollier's  most  valuable  experimental  and  clinical  researches 
upon  the  properties  of  this  tissue.  To  Yon  Langenbeck, 
by  whose  name  the  method  is  usually  known,  he  gives  only 
the  credit  of  being  the  first  to  adopt  Ollier's  suggestion,  and 
to  make  it  a  rule  of  practice. 

This  estimate  of  the  facts  does  not  seem  to  be  entirely 
correct.  It  is  true  that  Dieflenbach  used  double  lateral 
flaps,  but  a  large  part  of  the  success  of  the  modern  method 
is  due  to  the  greater  breadth  now  given  to  the  flaps.  Tillaux 
has  shown  that  the  branches  of  the  posterior  palatine  artery 
are  given  off"  like  the  j^lumes  of  a  feather,  and  that  to  avoid 
division  of  these  branches,  and  insure  the  nutrition  of  the 
flap,  the  incision  must  be  made  close  to  the  alveolar  process. 
This  necessity  is  as  absolute  in  the  case  of  a  small  perfora- 
tion as  in  that  of  a  large  one.  As  for  the  retention  of  the 
periosteum.  Yon  Langenbeck  was  certainly  the  first  to  point 
out  its  importance  as  a  means  of  preventing  gangrene  of  the 
flap.  Ollier's  investigations  turned  upon  its  value  in  favor- 
ing reproduction  of  the  bone. 

Fissure  of  the  hard  and  soft  palate  endangers  an  infant's 
life  by  interfering  with  the  ingestion  of  food.  The  exact 
measure  of  this  dano-er  has  not  yet  been  established  bv 
statistics,  but  it  is  certainly  considerable.^  On  the  other 
hand,  all  recorded  operations  for  cleft  palate  upon  children 
less  than  one  month  old  have  terminated  fatally,  and  those 
undertaken  during  the  first  five  or  six  months  of  the  child's 
life,  although  not  so  fatal,  show  but  few  successes.  Billroth 
and  Simon  think  the  operation  should  be  performed  about 
the  eighth  month,  but  most  surgeons  are  agreed  upon  the 

^  Chirurgie  Eeparatrice,  Art.  Uranoplastie. 

2  Lannelongue,  Mem.  cle  la  Soc.  de  Chirurgie,  1877,  p.  470. 


URANOPLASTY.  813 

|»ropriety  of  postponing  it  until  tlic  third  or  fourth  yvuv.  If 
M  c-liiM  has  lived  six  months  without  operation,  it  has  cer- 
tainly learned  to  overcome  the  mechanical  difficulties  in  the 
way  of  its  nourishment,  and  there  is,  conseijuentiy,  no  reikion 
to  interfere  surgically  until  the  second  indication  arises. 
That  is  found  in  the  defective  articulation  and  phonati«»n 
occasioned  hy  the  lesion,  and,  as  children  with  cleft  j)alate 
do  not  begin  to  speak  before  the  third  or  fourth  year,  the 
operation  may  be  safely  postponed  until  that  time. 

The  special  instruments  required  are  a  speculum  f>ris,  or 
two  blunt  hooks  to  be  place^l  at  the  angles  of  the  mouth  and 
fastened  together  by  a*  rubber  band  passing  behind  the 
head,  pronged  forceps  with  long  handles,  curved  needles  of 
the  pattern  selected,  a  periosteum  elevator  bent  at  a  right 
angle  on  the  flat,  a  small  knife  similarly  bent,  and  sponges 
on  long  handles. 

The  edges  of  the  perforation  or  fissure  are  first  freshened 
by  the  removal  of  a  strip  one  or  two  millimetres  thick.  An 
incision  is  then  made  on  each  side  close  to  the  gum,  extend- 
ing fi-om  the  last  molar  tooth  forward  as  far  as  may  be 
necessary,  and  ex|to>ing  the  bone  throughout.  The  elevator 
is  introduced  into  this  incision  and  the  periosteum  separated 
from  without  inward,  care  being  taken  not  to  injure  the 
palatine  arteries  at  the  anterior  and  posterior  palatine 
foramina. 

If  the  cleft  involves  the  soft  palate  its  sides  will  be  found 
to  round  off  toward  the  hamular  processes,  and  the  velum 
to  be  tightly  adherent  to  the  posterior  portion.  The  flaps 
cannot  be  brought  tocjether  until  the  attachments  of  the  two 
halves  of  the  velum  at  these  points  are  entirely  separated, 
a  step  which  may  be  accomplished  by  means  of  a  small, 
curved,  sharp  elevator  introduced  through  the  lateral  in- 
cisions, or  by  the  bent  knife  introduced  through  the  fissure. 

The  bleeding  during  this  stage  of  the  operation  is  ver}^ 
free,  but,  as  Ehrmann^  has  remarked,  usually  ceases  as  soon 
as  the  flaps  are  completely  liberated  If  it  continues  pres- 
sure should  be  made  for  a  few  moment^  with  the  finger,  or 
ice  applied.  Trelat  carries  his  incisions  further  back,  stop- 
ping from  one-fourth  to  one-half  an  inch  behind  the  pos- 

*  Meraoires   de  I'Acad.  de  Medecine,  vol.  xxxi. 

97 


314      OPERATIONS  UPON   MOUTH   AND   PHARYNX. 

terior  border  of  the  hard  palate,  and  entirely  disregarding 
the  posterior  palatine  artery. 

The  flaps  are  brought  together  in  the  median  line  and 
the  sutures  applied,  beginning  at  the  anterior  extremity  of 
the  cleft.  The  sutures  should  be  left  in  at  least  four  days 
and  tlien  removed,  not  all  at  once,  but  by  instalments. 


Fig.  198. 


Incisions  in  uranoplastj". 

If  the  fissure  is  unilateral,  the  vomer  remainino-  attached 
on  the  other  side.  Von  Lansenbeck  recommends  that  the 
lateral  incision  along  the  gum  should  be  made  only  upon  the 
side  occupied  by  the  fissure.  The  flap  on  the  other  side 
should  be  dissected  up  from  the  median  line  outward. 

If  the  fissure  extends  through  the  dental  arch  and  is  wide 
at  the  point,  Rouge^  recommends  that  one  of  the  flaps  should 

^  L'Uranoplastie  et  les  Divisions  Congenit.  du  Palai?,  1871,  p.  108. 


U  liANol'LAST  V.  315 

be  (k'tachod  in  front  also  and  swung  in  sideways  upon  tlio 
posterior  attaclnnent  as  a  centre. 

Fergusson  s  Oxt<'oplastic  Method.^ — In  1874  Sir  William 
Fergiisson  described  a  plan  which  he  had  siiccessfullv  em- 
ployed to  close  gJi})s  in  the  hard  palate  left  hy  the  partial 
failure  of  a  previous  operation,  adding  that  it  was  ecjually 
aj)})lical)le  to  those  cases,  frecpient  in  his  own  experience, 
in  which  the  front  part  of  the  cleft  had  been  left  untouched. 
He  made  an  incisi<jn  down  to  the  bone  on  each  side  of  the 
cleft,  midway  between  it  and  the  alveolar  process,  and  over- 
lapping it  a  little  at  each  end,  and  then  with  a  chisel  cut 
through  the  bone  at  the  bottom  of  the  incisions.  According 
to  Lannelongue,^  the  flow  of  blood  at  this  stage  of  the  ope- 
ration is  very  great,  but  is  easily  controlled  by  pressure. 
The  flaps  are  then  brought  together  in  the  median  line  and 
fastened  w^itli  sutures.  Fergusson  was  in  the  habit  of  pass- 
ing the  sutures  through  the  bone,  and  for  this  purpose 
drilled  holes  along  the  sides  of  the  cleft  before  he  made 
the  incisions.  Shortly  before  his  death,  he  gave  up  sutures 
entirely  and  kept  the  flaps  togetlier  by  plugging  the  lateral 
incisions  with  lint.  Lannelongue  considers  the  lint  dan- 
gerous, and  uses  sutures  passed  through  the  mucous  mem- 
brane only. 

Lannelonyue  s  Method  (nasal  flap). — Lannelongue  has 
closed  several  clefts  involving  only  the  hard  palate  by 
means  of  a  rectangular  flap  brought  down  from  the  side  of 
the  septum  of  the  nose.  The  flap  is  marked  out  by  a  hori- 
zontal and  two  vertical  incisions — the  former  parallel  to  the 
edge  of  the  cleft  and  at  a  suitable  distance  above  it,  the 
latter  extending  downward  from  each  end  of  the  horizontal 
one  to  the  angles  of  the  cleft.  The  flap,  composed  entirely 
of  the  mucous  membrane  of  the  septum,  is  dissected  from 
above  downward  with  a  curved  blunt  elevator  and  left  ad- 
herent at  its  inferior  border.  The  opposite  edge  of  the  cleft 
is  then  freshened  by  the  removal  of  a  superficial  strip  one- 

'  British  Medical  Journal,  April  4,  1874,  and  Braithwaite's  Retro- 
spect, vol.  Ixix.  p.  217, 

•^  Biilletius  de  la  Societe  de  Chirurgie,  1877,  p.  472. 


316      OPERATIONS  UPON   MOUTH    AND  PHARYNX. 

quarter  of  an  inch  broad,  and  the  u})per  border  of  the  Hap 
attached  to  it  with  sutures. 


STAPHYLOPLASTY. 

Schoenborn  describes^  a  plastic  operation  successfully  per- 
formed by  him  upon  a  girl  seventeen  years  old,  affected  with 
congenital  fissure  of  both  hard  and  soft  palates  extending  to 
the  anterior  palatine  foramen,  the  halves  of  the  velum  being 
very  deficient. 

The  patient  was  aniesthetized,  tracheotomy  performed, 
and  a  tampon-canula-  inserted.  After  having  pared  the 
edges  of  the  fissures  he  took  a  flap  four  or  five  centimetres 
long  and  two  centimetres  broad  from  the  posterior  wall  of 
the  pharynx,  its  base  directed  downward,  its  apex  situated 
as  high  as  possible,  so  that  it  would  reach  to  the  posterior 
edge  of  the  hard  palate  without  the  slightest  stretching. 

The  flap  was  composed  of  the  mucous  membrane  and  un- 
derlying muscle.  Its  dissection  is  difficult,  and  requires  a 
long  knife  with  a  cutting  edge  two  centimetres  long  turned 
down  at  right  angles  to  the  stem.  The  blade  should  be 
sharp  on  both  edges,  and  it  is  well  to  have  two  such  knives, 
one  blunt-,  the  other  sharp-pointed. 

The  upper  end  of  the  flap  was  caught  up  with  a  hook,  and 
the  dissection  made  from  above  downward,  the  knife  being 
kept  in  the  cellular  tissue  between  the  muscle  and  bone,  and 
its  edge  always  turned  away  from  the  flap. 

The  fibro-mucosa  of  the  hard  palate  was  then  freely  dis- 
sected up  in  the  usual  manner  (Von  Langenbeck's  method) 
until  it  and  the  soft  palate  had  been  made  sufficiently 
movable.  The  upper  corners  of  the  flap  were  then  cut  off, 
giving  it  a  triangular  shape,  and  it  was  brought  in  between 
the  halves  of  the  soft  palate  and  fastened  there  with  five 
points  of  suture.  The  fissure  in  the  hard  palate  was  closed 
with  three  points. 

^  Ueber  eine  neue  methode  der  Staphylorrhaphie.  Langenbeck's 
Archiv,  187G,  vol.  xix.  p.  527. 

'^  A  tracheotomy  tube,  the  middle  portion  of  which  is  enveloped  in 
a  rubber  pouch  which  can  be  expanded  so  as  to  fill  the  trachea  and 
prevent  any  liquids  from  finding  their  way  down  beside  it,  the  patient 
meanwhile  getting  his  supply  of  air  through  the  tube. 


STAI'II  YI.OPLASTY.  317 

The  tanipon-caimla  was  roplacod  noxt  day  by  a  silver  one. 
Swallowiiii;-  was  very  (lilVu'iill  lor  a  tew  days  ;  siij)j)iirali(jii 
ami  How  of  mucus  very  al)undant.  The  sutures  were  taken 
out  on  tlie  fif'tli  day.  Union  was  complete  on  tlie  ri^lit  side 
and  upper  part  of  the  left,  hut  had  failed  for  a  distance  of 
one  centinietre  between  the  tip  of  the  uvula  and  the  fla))  on 
the  left  side,  and  of  three  centimetres  in  the  hard  palate. 
The  latter  was  closed  by  another  operation  (Langenbeck's) 
in  January,  1875. 

The  tone  of  the  voice  and  the  distinctness  of  articulation 
were  immensely  imprinted  from  the  first,  and  after  a  few 
days  there  was  no  ditficulty  in  swallowing  or  in  breathing 
through  the  nose. 

This  operation  was  designed  to  meet  a  special  indication, 
of  which  mention  is  not  often  made.  It  is  well  known  that 
the  nasal  ({uality  of  the  voice  often  persists  after  a  fissure 
has  been  comjdetely  closed,  and  the  cause  has  been  supposed 
to  lie  in  the  fact  that  the  soft  palate  is  so  short  and  tense 
that  it  cannot  be  brought  into  contact  with  the  posterior 
wall  of  the  pharynx.  Passavant  proposed  to  meet  the  diffi- 
culty by  establishing  permanent  adhesion  between  the  velum 
and  pharynx,  basing  the  proposition  upon  cases  of  such  ad- 
hesion observed  by  himself  in  which  the  objectionable  nasal 
quality  was  absent  from  the  voice.  A  more  extensive  ex- 
perience, however,  has  shown  that  Passavant  was  in  error, 
or  that  his  observations  w^ere  incomplete.  If  the  adhesion 
is  complete,  or  nearly  so,  the  quality  of  the  voice  is  seri- 
ously aff'ected,  and  other  functional  troubles  are  occasioned. 
It  is  probable  that  the  good  result  in  Schoenborn's  case  was 
due  to  two  causes:  free  communication  left  between  the 
upper  and  lower  parts  of  the  pharynx  on  each  side  of  the 
flap,  and  ability  to  move  the  two  halves  of  the  palate  at 
will,  although  only  to  a  limited  extent.  The  method  seems 
to  be  worth  further  trial. 


EXCISION  OF  THE  TONGUE. 

Excision,  partial  or  complete,  may  be  rendered  necessary 
by  hypertrophy  of  the  tongue,  or  by  the  presence  of  a  tumor. 

27* 


318      OPERATIONS  UPON   MOUTH   AND  PHARYNX. 


Sedillot^  mentions  a  ease  of  hyj)ertropliy  in  Avliich  the 
tongue  projected  three  finger-breadths  beyond  the  lips,  and 
had  bent  down  the  anterior  portion  of  the  lower  jaw  to  such 
an  extent  that,  when  the  upper  and  lower  molar  teeth  were 
in  contact,  the  distance  between  the  incisors  in  the  median 
line  Avas  more  than  an  inch.  He  removed  the  projecting 
part  of  the  tongue  by  a  V-shaped  incision,  the  apex  directed 
backward  in  the  median  line,  and  brought  the  sides  together 
with  sutures.     Recovery  was  complete  and  prompt. 

Excision  may  be  performed  by  means  of  the  ligature, 
knife,  ecraseur,  or  galvano-cautery.  The  use  of  a  ligature, 
slowly  tightened  every  day,  has  fallen  into  disuse  since  the 
invention  of  the  ecraseur;  it  is  very  tedious  and  painful, 
and  the  tongue  is  liable  to  swell  enormously  during  the 

process. 

Fig.  19'J. 


Lee"6  clamp  to  prevent  bleeding  from  the  tongue. 

The  use  of  the  knife  exposes  to  severe  hemorrhage  unless 
the  portion  removed  is  small  and  favorably  situated.  Pre- 
liminary ligature  of  one  or  both  lingual  arteries  is  sometimes 
employed.  Mr.  Henry  Lee  has  devised  a  clamp  (Fig.  199) 
by  which  hemorrhage  from  the  anterior  portion  of  the  tongue 
can  be  completely  controlled. 

^  Medecine  Opera toi re,  vol.  ii.  p.  3o. 


EXCISION    OF    THE    TONGUE.  319 

Laii;ienbiK*k'  has  deviseil  a  method  of  so  placing  two 
tcmporarv  liiraturcs  upon  the  tongin*  tliat  bltvding  is  en- 
tirely prevented  <luring  the  removal  by  the  knife  of  any 
portion  of  the  anterior  half  or  even  two-thirds  of  the  mem- 
ber, lie  enters  the  jxunt  of  a  well  curved  needle  carrying 
a  stout  ligature  a  little  to  the  left  of  the  median  line  of  the 
tongue  behind  the  ]»ai*t  which  is  to  be  removed,  passes  it 
deeply  down  through  the  substance  of  the  tongue,  and 
brings  it  out  on  the  right  side  through  the  floor  of  the 
mouth  so  as  to  include  the  branches  of  the  lingual  artery  in 
its  loop.  To  prevent  slipping,  the  needle  is  then  passed 
through  the  edge  of  the  tongue  :  another  is  passed  in  the 
same  manner  on  the  opposite  side,  and  each  tied  tightly. 
The  ends  mav  then  be  used  to  draw  the  tongue  forward. 

It  has  also  been  suggested,  that,  when  it  is  necessary  to 
operate  very  far  back  upon  the  tongue,  its  base  can  be 
brought  forward  by  dislocating  the  lower  jaw  downward 
and  forwanl  simultaneously  on  both  sides. 

The  tongue  is  drawn  well  forward,  the  tumor  or  portion 
to  be  removed  seize<l  with  double  pronged  forceps  and 
rapidly  excised  by  a  V-shaped  incision  made  with  a  blunt- 
pointed  bistoury  so  as  to  avoid  injury  to  the  vessels  in  the 
floor  of  the  mouth:  all  bleeding  points  are  then  secured 
and  the  sides  of  the  wound  brought  together  with  sutures. 

If  a  larger  portion,  say  a  lateral  half,  of  the  tongue  is  to 
be  removed,  the  operation  may  be  done  as  follows :  Tw  o 
stout  ligatures  are  passed  through  the  tip,  one  on  each  side 
of  the  median  line,  to  be  used  to  draw  the  or^an  forward : 
the  tip  then  raised,  the  fr^num  cut  with  scissors,  and  the 
scissors  then  pushed  along  under  the  tongue  and  mucous 
membrane  to  free  them  as  far  back  as  necessary.  Then  the 
tongue  is  split  along  the  median  line,  fi'om  before  backward, 
completely  freed  from  the  underlying  parts  by  tearing  with 
the  finger,  the  mucous  membrane  of  the  floor  divided  with 
the  scissors,  and  the  posterior  section  made  with  knife  or 
scissors  or  with  the  ecraseur. 

Both  halves  can  be  removed  in  like  manner,  without  split- 
ting, by  freeing  below,  and  cutting  first  on  one  side  of  the 
floor  and  then  on  the  other,  and  tying  each  lingual  artery 
when  it  is  divided  in  the  wound. 

*  Archiv  fur  Klinische  Chirurgie,  vol.  xxii.  pa:  t  I.,  1878,  p.  72. 


320      OPERATIONS   UPON   MOUTH    AND   PHARYNX. 

Regnoli,  of  Pisa,  publislicd  in  1888  the  description  of  a 
method  by  which  lie  successfully  removed  the  anterior  por- 
tion of  the  tongue.  He  made  a  semicircular  incision 
through  the  skin  along  the  lower  border  of  the  jaw,  begin- 
ninii;  and  endino;  at  the  angles,  and  added  a  second  one  to 
it  in  the  median  line,  extending  to  the  hyoid  bone.  The 
tegumentarj  flaps  were  dissected  back,  and  the  muscles 
divided  at  their  attachments  to  the  inferior  maxilla.  The 
tongue  was  then  drawn  down  through  the  large  opening  thus 
made,  its  anterior  portion  readily  excised,  and  the  w^ound 
closed.  Billroth  has  revived  and  modified  Regnoli 's  opera- 
tion and  employed  it  in  several  cases.  It  has  the  advantage 
of  furnishing  free  drainage,  allowing  the  wound  to  be  treated 
antiseptically,  and  facilitating  the  removal  of  implicated 
lymphatic  glands.  A  curved  incision,  extending  1  to  IJ 
inches  on  each  side  of  the  symphysis,  is  made  in  the  under 
margin  of  the  jaw  and  carried  down  to  the  bone,  and  then 
it  is  enlarged  at  each  end  for  an  inch  downward  and  out- 
ward. The  periosteum  and  muscular  attachments  are  sepa- 
rated in  front  from  the  inside  of  the  jaw,  the  mouth  opened 
by  division  of  the  soft  parts  at  the  gums,  and  the  tongue 
drawn  out  through  the  cut. 

Lateral  Supra-hyoid  Method.  Kocher.^ — This  method 
has  for  its  object  the  very  thorough  removal  of  all  diseased 
tissues  of  the  tongue  and  pharynx  and  all  infected  glands  in 
the  neck.  Preliminary  laryngo-tracheotomy  is  necessary  to 
facilitate  the  operation  and  permit  antiseptic  treatment  of 
the  wound.  The  mouth  is  disinfected  by  washing  with  a 
salicylic  and  borax  solution. 

The  incision  is  made  from  the  under  border  of  the  lower 
jaw  near  the  symphysis,  in  the  direction  of  the  anterior 
belly  of  the  digastric,  to  the  hyoid  bone,  thence  backward  to 
the  anterior  border  of  the  sterno-cleido-mastoid,  and  then 
upward  along  it  to  or  above  the  angle  of  the  jaw  ;  after 
division  of  the  platysma  and  fascia  the  triangular  flap  is 
turned  up. 

The  submaxillary  fossa  is  then  emptied  by  removal  of  the 
submaxillary  and  diseased  lymphatic  glands,  the  facial  and 

1  Deutsche  Zeitschrift  fiir  Chir.,  1880,  vol,  134. 


EXCISION    OF    THE    TONGUE.  821 

liiiLTiKil  arteries  and  veins  having  been  divided  between 
doiilde  li<j:atines. 

The  larynx  and  (jesuphagus  are  then  covered  with  a  hirge 
sponge  forced  in  behind  the  tongue,  and  an  incision  made 
into  the  floor  of  the  mouth  ))y  cutting  througli  the  myhjhyoid 
muscle  close  to  the  jaw,  and  carried  along  the  bone  as  far  as 
mav  be  necessary. 

The  tongue  is  now  freely  accessible  through  the  wf»und. 
and  can  be  drawn  out  through  it  and  split,  and  cut  oft*  as 
near  its  base  as  is  desirable,  or  it  can  be  entirely  removed  in 
the  sjime  manner,  the  opposite  lingual  artery  being  readily 
secured  when  divided.  •  The  side,  and  even  the  posterior 
part  of  the  pharynx,  are  also  accessible. 

The  tracheotomy  tube  should  be  retained,  the  wound 
packed  with  antiseptic  gauze,  and  the  patient  fed  through 
an  oesophagus  tube. 

Sedillot,  commenting  upon  Regnoli's  case,  expresses  the 
opinion  that  the  excision  could  have  been  accomplished  (juite 
as  readilv  throu^rh  the  mouth,  and,  as  he  also  found  bv  ex- 
periments  upon  the  cadaver  that  the  tongue  cannot  be 
brought  far  enough  forward  through  such  an  opening  to 
facilitate  excision  at  or  near  its  base,  he  suggested  and  em- 
ployed division  of  the  inferior  maxilla  in  the  median  line  as 
a  preliminary  operation. 

Sedillofs  Method. — One  of  the  median  incisor  teeth  on 
the  lower  jaw  having  been  drawn,  an  incision  is  made  in 
the  median  line  from  the  free  border  of  the  lower  lip  to  the 
hyoid  bone,  and  the  jaw  sawn  through  in  the  line  of  the 
incision,  or.  better,  by  tw(»  obliiiue  lines  fomiing  a  <,  the 
apex  directed  to  one  side.  The  attachments  of  the  genio- 
hyo-glossus  muscles  to  the  bone  are  next  divided,  the  two 
halves  of  the  jaw  drawn  apart,  the  tongue  pulled  forward 
and  to  one  side,  and  its  attachments  to  the  hyoid  bone 
divided  on  the  other  side,  in  doing  which  the  lingual  artery 
is  divided  and  must  be  tied  at  once.  The  tissues  on  the 
other  side  are  then  divided  in  a  similar  manner,  and  the 
other  lingual  artery  having  been  tied  the  remaining  attach- 
ments are  severed  and  the  tonorue  removed. 

The  divided  maxilla  is  fastene<l  together  agajn  with  silver 
sutures  ])assed  through  holes  pierced  in  it  with  a  drill,  the 


322      OPERATIONS   UPON    MOUTH   AND   PHAKYNX 


sides  of  the  incision  in  the  lip  accurately  adjusted  to  each 
other,  and  the  lower  angle  of  the  wound  left  open  for  drainage. 

The  bone  has  sometimes  been  di- 
FiG.  200.  vided  in  the  side  instead  of  in  the 

median  line. 


Removal  hy  the  Ecraseur  (Fig. 
200). — The  chain  of  the  ecraseur,  a 
stout  wire,  or  a  ^vhip-cord  is  passed 
about  the  tongue  or  its  attachments 
at  the  selected  point  by  means  of  a 
needle  and  thread  or  a  trocar  and 
cunula,  and  slowly  tightened  until 
the  parts  included  in  the  loop  are  cut 
through.  As  the  operation  is  compa- 
ratively bloodless,  afia?sthesia  should 

Fig.  201. 


Hutchinsuu's  gag. 

be  used  and  the  mouth  held  open 
by  a  gag.  Hutchinson's  gag  (Fig. 
201)  is  very  convenient  and  takes 
up  but  little  room. 

Many  difterent  Avays  have  been 
suggested  for  passing  the  "wire  or 
chain.  For  removal  of  the  anterior 
portion  a  needle  carrying  a  ligature  may  be  passed  trans- 
versely under  the  tongue  and  used  to  conduct  a  chain  below 
it  and  back  across  its  dorsum.  After  tlie  tongue  has  been 
thus  divi(led  transversely  the  chain  is  passed  again  through 


Ecnuji'ur 


EXCISION    OK    THE    TONGUE.  323 

the  iiii-isi(»ii,  iiK'liidin;:;  in  its  loop  the  iiilcrior  attuflinicnts  of 
the  anterior  portion.  Or  tlie  first  ligature  may  he  douhle 
and  two  ecraseurs  usc<l  sinndtaneously. 

Mirault  c-arricd  a  donhle  li^jjature  throu^rh  tlic  centre  of 
tlie  tongue  from  helow  u})ward  by  means  of  a  needle  [)assed 
throiiirh  a  small  incision  in  the  skin  in  the  median  line  of 
the  supra-hyoid  region.  The  ligature  was  then  cut  in  two. 
each  end  carried  around  a  lateral  half  of  the  tongue  and 
brought  out  through  the  original  opening.  A  third  ligature 
■was  then  carried  horizontally  about  the  inferior  attachments 
of  the  portion  to  be  rentioved. 

Cloquet  removed  a  hiteral  portion  of  the  tongue  by  pass- 
ing a  double  ligature  in  the  manner  just  described,  and 
phicing  one  of  the  loops  in  an  antero-posterior  position  so 
that  it  divided  the  tongue  along  the  median  line. 

Sir  James  Pajzet  drew  the  tongue  forward,  divided  the 
mucous  membrane  and  the  soft  parts  of  the  floor  of  the 
mouth  close  to  the  bone,  including  the  attacliments  of  the 
genio-hyo-glossi  to  the  symphysis,  and  then  passed  the  chain 
of  the  ecraseur  around  the  root  of  the  tongue  as  low  down 
as  possible,  so  as  to  encircle  it  and  all  the  remaining  inferior 
attachments. 

The  galvano-cautery  is  used  either  in  the  form  of  a  knife 
or  as  the  wire  of  an  ecraseur ;  no  additional  directions  are 
required  beyond  the  caution  that  the  temperature  should  be 
raised  to  red  heat  only.  At  a  higher  temperature  the  parts 
are  divided  more  rapidly,  and  bleeding  is  likely  to  occur. 


DIVISION  OF  THE  FRJ^NUM. 

The  tip  of  the  tongue  is  raised  upon  the  handle  of  a 
director,  in  the  slit  of  which  the  fr?enum  is  engaged,  and 
divided  with  curved  scissors  close  to  the  director.  Only 
the  semi-transparent  edge  of  the  constricting  band  should 
be  cut,  and  then  the  rest  torn  by  pressing  the  tongue  up 
toward  the  roof  of  the  mouth.  If  the  ranine  vessels  should 
chance  to  be  divided  the  bleeding  can  be  controlled  by 
touching  the  points  with  nitrate  of  silver  or,  if  necessary, 
with  the  actual  cautery.     J.  L.  Petit  reported  a  case  of  suf- 


324      OPERATIONS   UPON    MOUTH   AND   PHARYNX. 

focatioij  cause<l  by  tlie  tongue  falling  back  ujion  tlie  glottis 
after  division  of  the  frnenuin,  and  Guerin  mentions  another. 


KAXULA. 

'J'ho  anterior  wall  of  the  cvst  sliould  be  caught  up  with 
toothed  fb)-ceps  and  excised.  A  director  should  be  passed 
at  intervals  between  the  sides  of  the  incision  to  prevent  re- 
union, and  the  filling  up  of  the  sac  may  be  hastened  by 
paijiting  its  interior  with  nitric  acid  or  tincture  of  iodine. 
In  some  cases  it  is  sufficient  to  pass  a  thread  or  wire  seton 
through  the  cyst. 


SALIVARY  FISTULA. 

Salivary  fistula  communicating  directly  with  portions  of 
the  parotid  gland  can  usually  be  closed  by  cauterization 
and  compression,  but  when  the  fistula  communicates  with 
Steno's  duct  the  cure  is  much  more  difficult.  If  the  distal 
portion  of  the  duct  is  still  permeable  a  leaden  wire  may  be 
passed  through  it  from  the  mouth  into  the  proximal  portion 
of  the  duct.  The  saliva  will  follow  the  wire,  and  if  the 
fistula  does  not  close  spontaneously  its  edges  should  be 
pared  and  brought  together  with  sutures.  The  orifice  of 
the  duct  is  readily  found  opposite  the  second  upper  molar 
tooth. 

When  the  distal  portion  of  the  duct  is  obliterated  either 
one  of  two  methods  may  be  employed.  The  fii'st  is  that  of 
Deguiso,  and  consists  in  the  formation  of  a  new  channel  in 
the  cheek  for  the  saliva ;  the  second  is  that  of  Prof.  Van 
Buren,  and  consists  in  the  bodily  transfer  of  the  fistulous 
orifice  from  the  outer  to  the  inner  surface  of  the  cheek. 

Deguise's  Method. — Deguise  made  a  puncture  through 
the  fistulous  opening  obliquely  backwaid  to  the  inner  sur- 
face of  the  cheek  and  passed  one  end  of  a  leaden  wire 
through  it ;  he  next  made  through  the  same  opening  a 
second  puncture  directed  obliquely  forward,  brought  the 
other   end  of  the  wire   throush   it   and  tied   the  two  ends 


BRONCHOTOM  V.  325 

toi!;otlkM'.  The  loop  (»r  (lie  wire  IxMiiLi;  thus  diiiwii  into  lli(> 
fistula  the  saliva  followed  its  two  hniuches  into  tin-  mouth, 
and  tho  fistula  hcalod  at  once.  Some  surii:('ons  use  a  silk 
ligature  and  tie  it  tightly  so  as  to  cut  through  the  tissues 
ineluded  in  the  loop. 

Prof.  Viin  Barcn^  cured  a  salivai-y  fistula,  tho  result  of 
a  ujunshot  wound,  hv  passini:;  two  fine  silver  wires  thi'ou'di 
the  skin  at  o])posite  points  on  its  vdifo,  then  isolating  the 
duct  and  fistulous  opening  for  half  an  inch  by  dissection 
backward  from  the  latter,  making  an  incision  through  the 
wound  to  the  inner  side  of  the  cheek,  drawing  the  fistulous 
opening  through  it,  and  fastening  it  there  by  means  of  the 
wires.  The  gap  left  on  the  cheek  was  then  closed  with  fine 
silver  sutures. 

The  duct  was  so  short,  the  fistula  being  an  inch  behind 
the  anterior  margin  of  the  masseter,  that  it  could  not  be 
brought  <[uite  to  the  inner  surface  of  the  cheek.  The  wires, 
however,  which  were  left  in  place  until  the  fifth  week,  kept 
o})en  a  track,  which  became  permanent,  for  the  })assage  of 
the  saliva  from  the  end  of  the  duct  to  the  mouth. 


CIIAPTKll    IV. 

01M]RATI0NS  l'KRFORMI]D  UPON  THE  NECK. 
RRONOUOTOMY. 

This  is  a  general  term  covering  operations  undertaken  to 
open  the  larynx  or  cervical  portion  of  the  trachea.  These 
operations  are :  ,  Lari/ni/otoinj/,  trtwln'otomt/,  and  larywio- 
tracJteotonn/.  Laryngotomy  is  further  subdivided  into  siib- 
hyoid  Ictrifutiotoiifji  (called  sxprtf-Ian/ni/ral  hro)i<'hoto)in/ 
by  Sedillot,  and  indirect  Iari/n</<>t<>)ni/  by  IManchon),  t/tt/- 
roid   lart/nr/otonif/,    and    rrico-tht/roid    larymiotomy.     The 

•  New  York  Mcdicrtl  Joiirnal,  vol.   i.   p.  ")o,  nnd  Contrilxitioiis  to 
PiucLical  Siiri;ory,  ISO"),  p.  '20'). 

28 


326  OPERATIOXS    UPON    THE    NECK. 

names  indicate  the  points  at  wliicli  tlie  opening  is  made  into 
the  air-passages. 

Suh-hyoid  Laryngotomy. — This  operation,  originally  per- 
formed upon  animals  by  Bichat  for  the  purpose  of  studying 
the  movements  of  the  vocal  cords,  was  afterwards  proposed 
by  Vidal  to  give  access  to  an  abscess  situated  in  the  glotto- 
epiglottidean  folds,  and  by  Malgaigne  to  allow  the  removal 
of  a  foreign  bo<ly  lodged  in  the  upper  part  of  the  larynx. 
It  is  also  applicable  to  the  removal  of  polyps  situated  at  the 
same  point  and  not  accessible  through  the  mouth.  Follin 
thus  removed  ten  from  the  anterior  surface  of  the  arytenoid 
cartilages. 

A  transverse  incision  two  inches  long,  its  centre  in  the 
median  line,  is  made  through  the  skin  immediately  below 
the  hyoid  bone,  and  the  platysma,  sterno-hyoid  muscles, 
and  thyro-hyoid  membrane  divided.  The  mucous  mem- 
l)rane  lying  between  the  epiglottis  and  the  base  of  the 
tongue  then  presents  in  the  incision,  is  drawn  downward 
with  forceps,  and  opened  with  the  knife  or  scissors.  The 
epiglottis  is  then  seized  with  a  hook  or  pronged  forceps  and 
drawn  out  through  the  wound,  freely  exposing  the  larynx  to 
view. 

Yelpeau  made  the  first  incision  in  the  median  line,  di- 
vided the  thyro-hyoid  membrane  transversely,  and  then 
plunged  the  knife  backward  and  downward,  making  a  ver- 
tical incision  in  the  base  of  the  epiglottis  through  which  he 
passed  the  blades  of  a  pair  of  forceps  and  withdrew  the 
foreign  body. 

Thyroid  L<iryn<ii>toniy. — In  this  operation  the  thyroid 
cartilage  is  divided  vertically  in  the  median  line,  between 
the  anterior  attachments  of  the  vocal  cords.  It  is  suitable 
for  the  removal  of  foreign  bodies  or  polyps  from  the  inte- 
rior of  the  larynx. 

Steadying  the  larynx  with  the  thumb  and  forefinger  of 
his  left  hand,  the  surgeon  makes  an  incision  along  the  pro- 
jecting angle  of  the  thyroid  cartilage  in  the  median  line, 
from  its  upper  border  to  the  cricoid  cartilage-  As  soon  as 
the  crico-thyroid  membrane  is  exposed,  he  makes  a  small 
opening  in  it  near  its  upper  border  and  passes  one  blade  of 


LARYNGOTUMV.  327 

a  strong  blunt-pointeil  pair  of  scis^soi-s  tlirough  it  to  the 
upper  border  of  the  hirviix,  keeping  exactly  in  the  median 
line,  and  tliiis  divides  the  thyroid  cartilage  throughout  its 
entire  length.  Or  a  grooved  director  may  be  passed  through 
the  opening  made  in  the  crico-thyroid  membrane,  and  the 
cartilage  divided  upon  it  with  a  curve<l  bistoury.  Or,  again, 
the  division  may  be  made  with  the  knife,  layer  by  layer, 
from  before  backward. 

Crico-thyroid  Laryn>iotomn. — In  this  operation  the  open- 
ing is  made  in  the  crico-thyr<jid  membrane.  The  French 
writei-s,  Sedillot,  Dubru'eil,  Chauvel,  speak  of  this  method 
as  having  been  entirely  abandoned  because  the  opening 
cannot  be  made  sufficiently  large.  Holmes,  on  the  other 
hand,  considers  it  suitable  in  all  cases  in  which  only  the 
vocal  cords  or  the  tissues  above  them  are  involved,  and  says 
it  is  practised  in  spasm  of  the  glottis  from  any  cause,  in 
erysipelatous  affections  spreading  down  the  throat,  and  in 
cases  of  foreign  body  lodged  in  or  above  the  glottis.  If 
the  opening  proves  to  be  too  small  it  can  be  enlarged  down- 
ward through  the  cricoid  cartilage  (laryngo-trache<:)tomy). 
The  operation  may  be  re«|uired  in  cases  of  urgency  when 
no  tube  is  at  hand.  A  pair  of  forceps  or  scissors,  a  hair- 
pin, or  pieces  of  bent  wire  will  suffice  to  keep  the  wound 
open,  and  the  incision  can  be  made  with  a  penknife. 

Ope  ration . — Dorsal  decubitus,  shouldei-s  raised  upon  a 
cushion  or  narrow  pillow  so  that  the  head  may  fall  back 
and  keep  the  throat  tense.  The  surgeon,  standing  at  the 
patient's  right  side,  fixes  the  larynx  with  his  left  thumb  and 
middle  finger  placed  on  either  side,  and  the  index  upon  its 
upper  border,  and  makes  a  cutaneous  incision  in  the  median 
line  corresponding  to  the  crico-thyroid  membrane.  He  draws 
the  sterno-thvroicl  muscles  apart,  lavs  bare  the  membrane, 
and  divides  it  transversely  or  vertically ;  m  the  latter  case 
the  incision  should  begin  a  short  distance  below  the  inferior 
border  of  the  thyroid  cartilage,  so  as  to  avoid  a  small  artery 
which  crosses  at  that  point,  and  extend  to  the  cricoid 
cartilage.  (For  the  method  of  inserting  the  canula  see 
Trarht'^tomy.) 


328  OPERATIONS    UPON    THE    NECK. 

Lai'yngo-tracheotomy . — The  opening  occupies  part  of  the 
crico-thyroid  membrane,  the  cricoid  cartilage,  and  the  first 
two  or  three  rings  of  the  trachea.  The  upper  border  of  the 
isthmus  of  the  thyroid  usually  corresponds  to  the  second 
ring  of  the  trachea ;  it  should  not  be  divided.  In  children 
under  six  years  it  commonly  rises  to  the  lower  border  of  the 
cricoid  cartilage. 

Dorsal  decubitus,  with  shoulders  raised,  head  thrown 
back,  and  neck  slightly  stretched.  The  larynx  is  fixed  as 
for  crico-thyroid  laryngotomy,  and  an  incision  made  through 
the  skin  exactly  in  the  median  line  from  the  middle  of  the 
thyroid  cartilage  to  about  one  inch  below  the  cricoid.  The 
muscles  are  carefully  drawn  apart,  the  isthmus  of  the  thy- 
roid depressed  if  necessary,  after  nicking  and  tearing  with 
blunt  hooks  the  suspensory  fascia  at  its  upper  border,  the 
trachea  steadied  and  drawn  upAvard  with  a  sharp  hook 
thrust  into  the  upper  part  of  the  crico-thyroid  membrane, 
and  the  point  of  the  bistoury  entered  close  below  the  hook 
and  made  to  cut  downward  through  the  cricoid  cartilage  and 
one  or  two  rino-s  of  the  trachea.  The  edo-es  of  the  incision 
are  then  held  apart  and  the  canula  introduced,  or  the  forceps 
if  the  operation  has  been  undertaken  Avith  a  view  to  the 
removal  of  a  foreign  body  or  a  polyp. 

De  Saint  G-ermains  Method. — Dorsal  decubitus,  shoul- 
ders raised,  neck  extended.  The  surgeon  feels  for  the 
cricoid  and  thyroid  cartilages,  and  the  depression  between 
them.  Then,  standing  upon  the  patient's  right  side,  he 
places  his  left  thumb  and  middle  finger  on  either  side  of  the 
larynx,  and  by  pressing  them  in  betAveen  it  and  the  ver- 
tebral column,  pushes  the  larynx  forAvard,  makes  tense  the 
skin  covering  it,  and  at  the  same  time  marks  the  situation 
of  the  lower  border  of  the  thyroid  cartilage  A\^ith  the  nail  of 
his  left  forefino-er. 

The  knife,  a  straight  sharp-pointed  bistoury,  is  held  like 
a  pen*,  its  back  directed  upAvard,  and  the  middle  finger  so 
placed  upon  its  side  as  to  limit  to  half  an  inch  the  depth 
to  AAdiich  the  point  can  penetrate.  It  is  then  entered  Avith 
a  quick  sharp  stab  in  the  median  line  close  against  the  nail 
of  the  left  forefinger  and  made  to  cut  doAvnAvard  Avith  a 
saAvino;  motion  throus^h  the  cricoid  cartilao-e  and  one  or  tAvo 


TKACll  EOTOMV.  329 

tracheal  riiio-s,  niro  being  taken  to  iiKikc  ilic  incision  in  ilic 
skin  fully  as  long  as  that  in  the  traehcii.  The  wound  is 
held  open  wiih  a  "dilator,"  and  the  c;iniila  introdueed  be- 
tween its  branches;  the  ])ressure  of  the  latter  is  usiuilly 
sufficient  to  arrest  hemorrhage,  but  ligatures  can  be  easily 
applied  if  necessary.  In  only  one  case  out  of  ninety-seven 
did  Saint  Germain  injure  the  posterior  wall  of  the  trachea, 
and  in  only  three  did  hemorrhage  occur.' 

Travh'otomy. — The  trachea  may  be  opened  at  any  j)oint 
between  the  cricoid  caiitilage  and  the  upper  border  of  the 
sternum,  a  distance  averaging  in  the  adult  from  two  and 
one-half  to  three  inches,  in  the  child  under  ten  years  of  age 
from  one  and  one-half  to  two  and  one-half  inches.  Its  course 
is  obli(|uely  backward  as  well  as  downward,  so  that  while 
its  upper  end  is  almost  subcutaneous  it  becomes  deeply  placed 
before  it  passes  behind  the  sternum.  It  is  crossed  at  its 
upper  end  by  the  isthmus  of  the  thyroid  gland,  the  breadth, 
thickness,  and  vascularity  of  which  vary  within  very  wide 
limits,  although  its  upper  border  usually  corresponds  to  the 
second  ring  of  the  trachea.  A  communicating  branch  unit- 
ing the  two  inferior  thyroid  arteries  crosses  just  below  the 
lower  border  of  the  isthmus.  The  lower  portion  is  covered 
anteriorly  by  the  thyroid  veins,  always  greatly  distended 
when  the  respiration  is  obstructed,  and  l>y  the  thymus  gland 
in  children  under  two  years  of  age,  and  occasionally  in  un- 
healthy older  ones. 

To  the  dangers  depending  upon  the  normal  arrangement  of 
the  parts  are  added  those  of  not  infrecjuent  anomalies  in  the 
origin  and  course  of  the  arteries  and  veins.  Thus,  the  left 
brachio-cephalic  vein  may  cross  the  trachea  well  al)ove  the 
sternum,  the  left  carotid  may  arise  from  the  innominate,  and 
sometimes  an  inferior  thyroid  artery  is  given  oft'  from  the 
transverse  portion  of  the  arch  of  the  aorta,  and  ascends 
along  the  anterior  surface  of  the  trachea  in  the  median  line. 
Finally,  an  aneurism  of  the  innominate,  or  of  the  arch  of 
the  aorta,  may  rise  in  front  of  this  portion  of  the  trachea. 

Operation. — The  patient  is  placed  upon  his  back  with 
shoulders  raised   and  head    thrown   back.     A  trustworthy 

1  Bull,  de  la  Soci^te  de  Chirurgie,  1^77,  i»i).  271  mid  327. 

28* 


330  OPERATIONS    UPON    THE    NECK. 

assistant,  standins:  behind  the  head,  hohls  it  firmlv  in  a 
straight  line  witli  the  body ;  others  control  the  patient's 
limbs  if  he  has  not  been  an;^sthetized.  The  surgeon,  stand- 
ing at  the  patient's  right  side,  recognizes  with  his  finger  the 
lijoid  bone  and  thyroid  and  cricoid  cartilages,  and,  marking 
with  his  left  forefinger  the  lower  border  of  the  cricoid  carti- 
lage, makes  an  incision  downward  from  it  in  the  median  line 
from  one  and  one-half  to  two  inches  in  lenorth,  accordino;  to 
the  size  of  the  patient.  He  carries  the  incision  through  the 
skin  and  fjiscia.  separates  the  sterno-hyoid  and  sterno-thyroid 
nniscles  with  the  handle  of  his  knife,  and  lays  bare  the 
isthmus  of  the  thyroid.  If  any  large  veins  are  encountered, 
they  must  be  carefully  drawn  aside  or  divided  between  two 
ligatures,  but  bleedino:  from  smaller  ones  may  be  safely  dis- 
regarded,  for.  as  Trousseau  pointed  out,  it  will  cease  as  soon 
as  the  trachea  is  opened,  and  the  venous  congestion  relieved 
by  the  admission  of  air  to  the  lungs. 

It  is  well  to  have  one  or  tAvo  assistants  hold  the  sides  of 
the  incision  apart  during  the  dissection,  if  they  can  be  de- 
pended upon  to  do  so  without  disturbing  the  relations  of  the 
parts  by  drawing  too  forcibly  toward  one  side  or  the  other. 

The  isthmus  of  the  thyroid  is  next  drawn  upward  with  a 
blunt  hook,  and  three  or  four  rings  of  the  trachea  exposed 
below  it,  and  divided  from  below  upward.  If  for  any 
reason  it  is  desirable  to  make  the  incision  higher  up,  or  if 
the  isthmus  is  unusually  broad,  it  may  be  divided  between 
two  ligatures,  in  which  case  the  incision  of  the  trachea  should 
be  made  from  the  lower  Ijorder  of  the  cricoid  cartilage  down- 
ward. 

The  incision  in  the  trachea  should  always  l)e  fi'ee  enough 
to  admit  the  canula  readily,  and  sliould  be  made  by  a  (|uick 
thrust  with  a  sharp-pointed  knife,  which  must  be  prevented 
from  penetrating  too  deeply  at  first,  by  holding  it  close  to 
its  point.  After  the  puncture  has  been  thus  made,  it  is 
enlarged  by  gentle  sawing  movements  of  the  knife,  or  with 
scissors. 

The  knife  is  retained  in  the  trachea  as  a  guide,  until  the 
dilator  or  bivalve  canula  (Figs.  202  and  203)  has  been  in- 
troduced. The  best  dilator  is  the  three-bladed  one;  it  is 
introduced  closed,  its  blades  then  expanded,  and  the  perma- 
nent canula  passed  in  between  them.     The  canula  should  be 


(ESOPHAGOTOMY 


331 


curved,  (loulde  to  facilitate  clcanin;^,  ;in<l  with  an  opening  on 
its  convexity,  through  which  the  expired  air  can  pass  to  the 
larvnx. 

Some  sur'a'ons  steady  the  tracliea  l»v  drawinir  it  toward 
the  chin  with  a  tenaculum  introduced  at  the  lower  edire  of 


Fig.  202. 


Fig.  203. 


Bivalve  canula  clo:;>e<l. 


Bivalve  cauula  with  tube  iu  place. 


the  cricoid  cartilage.  Gurdon  Buck  u.sed  for  this  purpose 
a  rather  narrow  lance-shaped  knife,  bent  at  a  right  angle  on 
the  flat,  and  also  grooved  on  the  back  for  use  as  a  director. 

Galvano-  or  Thei'ino-cautery.  —  The  danger  of  hemor- 
rhage, e.-^pecially  in  the  adult,  has  led  many  surgeons  to  use 
the  galvano-  or  thermo-cautery.  Its  hemostatic  advantages, 
however,  are  offset  by  a  large  eschar  which  it  causes,  and 
the  possible  necrosis  of  the  tracheal  cartilages.^  The  cautery 
should  be  used  only  to  divide  the  soft  parts,  the  trachea 
should  be  opened  with  the  knife.  Saint  Gennain  has  also 
sought  to  prevent  hemorrhage  by  making  the  incision  with 
a  red-hot  bistoury. 

(ESOPHAGOTOMY. 

The  oe.sophagus  begins  in  front  of  the  sixth  cervical  ver- 
tebra in  the  median  line,  or  just  behind  tlie  cricoid  cartilage: 


'  See  the  discussion  in  the  Soci^t^  de  Chirurgie,  May  9  to  June  13, 

1877. 


332 


OPERATIONS    UPON    THE    NECK. 


at  first  it  inclines  slightly  toward  the  left,  then  returns  to 
the  median  line  as  it  passes  behind  the  sternum,  inclines  to 
the  right  at  the  arch  of  the  aorta,  and  again  to  tlie  left  as 
it  approaches  the  diaphragm.  The  left  recurrent  laryngeal 
nerve  lies  between  its  cervical  portion  and  the  trachea,  the 
right  recurrent  nerve  lies  upon  its  outer  side.  It  is  covered 
anteriorly  bv  the  trachea  and  left  lobe  of  the  thyroid  gland, 
and  crossed  by  the  left  inferior  thyroid  arteiy  and  vein. 
The  guide  to  it  is  the  trachea.  The  operation  of  external 
cesophagot'omy  may  be  required  for  the  relief  of  stricture,  or 
the  removal  of  a  f  »reign  body.  In  the  former  case,  it  may 
be  performed  above  or  at  the  level  of  the  stricture  for  the 
purpose  of  dividing  or  dilating  it,  or  below  the  stricture  so 
as  to  allow  the  introduction  of  food  into  the  stomach.  The 
left  side  of  the  oesophagus  is  more  accessible  in  the  neck  than 
the  right,  and  the  incision  may  be  made  in  the  median  line 
or  parallel  to  the  inner  border  of  the  sterno-cleido-mastoid 
muscle.  As  the  walls  of  the  oesophagus  are  flaccid,  a  guide 
should  be  used  if  it  is  possible  to  introduce  one.  The  best 
one  is  the  instrument  known  as  Yacca-Berlinghieri's  sound 
(Fig.  204).     It  is  a  hollow  metallic  instrument,  cui'ved  at 


Fig.  201. 


Vacca-Berlingbieri's  oesophageal  sound. 


one  end  like  a  urethral  sound,  but  to  a  less  degree,  with  a 
loner  opening  in  the  concavity  or  on  the  left  side,  extending 
not\uite  to  the  end.  Within  the  sound  is  an  elastic  staff, 
the  side  of  which  can  be  made  to  project  through  the  open- 
ing and  distend  the  oesophagus,  its  point  being  engaged  in 
the  cul-de-sac  at  the  extremity  of  the  sound.  In  some  cases 
the  foreign  body  can  be  used  as  a  guide. 

Lateral  Imision. — Dorsal  decubitus,  head  extended,  face 
turned  slightly  to  the  right.  The  surgeon,  standing  at  the 
patient's  left,  'makes  an  incision  through  the  skin,  subcutane- 
ous cellular  tissue,  and  the  platysma  a  httle  on  the  inner  side 


AMI'UTATlON    OF    THK     HKEAST.  383 

of  tlu'  inner  border  of  the  storno-clci<l()-ni:ist(>i<]  ironi  ;i  jxtint 
one  ineli  ;il>o\e  tlie  sternum  to  tlie  level  of  the  upper  border 
of  the  thyroid  cartilage.  If  the  external  or  anterior  jugular 
is  encountered,  it  must  be  drawn  aside  or  divided  between 
two  ligatures.  The  fascia  is  then  divided,  the  omo-byoid 
muscle  drawn  aside,  and  then  the  side  of  the  thyroid  <:land 
followed  downward.  The  sterno-cleido-mastoid  and  the  sreat 
vessels  are  drawn  outward  Avith  a  blunt  hook,  the  trachea 
and  thyroid  ijjland  to  the  rii-ht,  and  tlien  the  surgeon,  work- 
ing  with  his  fingers  or  blunt  instruments,  separates  tlie  tis- 
sues at  the  bottom  of  the  wound  and  exposes  the  oesophagus, 
which  can  be  recognized  by  its  flattened  appearance  and 
muscular  wall.  If  more  room  is  needed,  tlie  sternal  head  of 
the  sterno-cleido-mastoid  must  be  divided.  A^acca's  sound 
is  then  introduced  through  the  mouth,  its  elastic  staff  pro- 
jected through  the  lateral  opening  so  as  to  distend  the 
oesophagus,  and  recognized  by  the  finger  at  the  bottom  of 
the  wound.  The  surgeon,  having  satisfied  himself  that  the 
recurrent  laryngeal  nerve  and  inferior  thyroid  artery  are  out 
of  the  way,  punctures  the  oesophagus  by  picking  it  up  with 
two  hooks  or  toothed  forceps  and  cutting  between  them, 
and  enlarges  the  opening  with  scissors  or  a  blunt-pointed 
bistoury. 

Median  Incisioyi. — Tlie  incision  is  the  same  as  in  trache- 
otomy. After  the  trachea  has  been  exposed  in  the  median 
line,  the  surgeon  separates  it  on  the  left  side  with  a  director 
from  the  sterno-thyroid  and  sterno-hyoid  muscles,  and  opens 
the  oesophagus  on  the  outer  side  of  the  recurrent  laryngeal 
nerve. 


CHAPTER  V. 

OPERATIONS  UPON  THE  THORAX. 
AMPUTATION  OF  THE  BREAST. 

The  patient  is  placed  upon  her  back,  inclined  somewhat 
toward  the  opposite  side,  and  the  arm  aliducted  so  as  to 
make  the  skin  and  pectoral  muscle  tense.     Two  curved  in- 


334  OPERATIOXS    UPON    THE    THORAX. 

cisions  are  made,  one  ou  each  side  of  the  nipple,  inclosing 
an  elliptical  strip  of  skin  of  greater  or  less  breadth  accord- 
ing to  circumstances,  the  lonf:  axis  of  which  is  directed 
toward  the  axilla ;  that  is,  upward  and  backward.  The 
upjier  and  lower  skin  flaps  are  then  dissected  oif  the  anterior 
surface  of  the  gland,  its  upper  border  turned,  exposing  the 
pectoral  muscle,  if  necessary,  and  the  loose  cellular  tissue 
between  it  and  the  muscle  rapidly  divided  with  a  few  strokes 
of  the  knife,  beginning  at  the  upper  border  of  the  inner 
angle,  while  the  cdand  is  drawn  away  from  the  chest  wall. 
and  the  removal  completed  along  the  lower  incision,  or  at 
the  axillary  angle  of  the  wound. 

Bleeding  during  the  operation  must  be  controlled  by 
clamps  upon  the  bleeding  points,  and  the  vessels  secured 
afterward  with  ligatures  or  by  torsion. 

If  the  axillary  glands  are  involved,  the  incision  must  be 
extended  upward  across  the  axilla  to  the  arm,  and  the  glands 
dissected  off  the  vessels  and  removed  en  masse,  with  the  fat 
and  connective  tissue  interposed  between  them  and  the 
breast. 

PARACENTESIS  OF  THE  THORAX. 

Each  of  the  lower  posterior  intercostal  arteries  enters  its 
corresponding  intercostal  space  near  the  spinal  column,  and 
passes  oblifpiely  from  below  upward  across  the  space  to 
shelter  itself  in  a  groove  on  the  inner  side  of  the  lower 
border  of  the  upper  rib.  It  occupies  this  groove  until  it 
reaches  the  anterior  third  of  the  space,  when  it  leaves  it  to 
anastomose  with  the  branches  of  the  anterior  intercostal 
artery  coming  from  the  internal  mammary.  At  this  point, 
however,  it  is  so  small  that  its  division  is  not  of  much  con- 
sequence. The  only  part  of  its  course  where  its  injury  is 
to  be  feared  is  in  the  posterior  third  of  the  intercostal  space 
before  it  has  passeil  behind  the  lip  of  the  rib.  Consequently, 
if  an  opening  is  to  be  made  into  the  pleural  cavity,  either 
with  a  knife  or  trocar,  a  point  in  the  middle  third  of  one  of 
the  intercostal  spaces  should  be  selected,  preferably  the 
seventh,  certainly  not  higher  than  the  sixth,  nor  lower  than 
the  eighth  on  the  right  side,  the  ninth  on  the  left. 

After  determining  the  position  of  the  intercostal  space. 


PARACENTESIS    OF    THE    PERICARDIUM.      335 

often  :i  matter  of  coiisiderjiblc  difiiculty  in  consc(jiU'ncc  of 
the  iniiltration  of  the  parts,  make  an  incision  jiarallel  to  it, 
one  or  one  and  one-half  Indies  in  length.  Divide  the  tissues 
layer  by  layer,  until  the  rib  can  be  distinctly  felt  with  the 
fiuixer  introduced  into  the  wound.  Place  the  end  of  the 
finger  upon  the  upper  border  of  the  lower  rib,  and,  keeping 
the  knife  close  to  the  border,  divide  the  muscles  and  pleura. 

Fia.  205. 


Paracentesis  of  thorax. 


If  a  trocar  or  the  aspirator  is  used,  it  must  be  thrust  in 
with  a  sharp  push  so  as  certainly  to  penetrate  the  pleura, 
which  is  often  thick  and  tough.  The  outer  end  of  the 
canula  should  be  wrapped  in  a  long  sleeve  of  moistened 
gold-beater's  skin,  which  will  hang  down  over  its  orifice, 
and,  while  permitting  the  escape  of  the  pus,  will  prevent 
the  entrance  of  the  air  (Fig.  20o) ;  or,  as  suggested  by  Dr. 
Flint,  a  David.son  syringe  can  be  attached  to  the  trocar. 

See  also  Resection  of  the  ribs,  page  192. 


PARACENTESIS  OF  THE  PERICARDIUM. 


Normally  the  pericardium  is  in  contact  with  the  chest 
wall  only  in  the  median  line  under  the  sternum  ;  but  when 
its  sac  is  distended  with  liquid  the  area  of  contact  becomes 
much  larger,  especially  by  extension  downward  and  to  the 
left.     The  heart  is  at  the  same  time  pressed  upward  and 


3oG      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

backward.  Tlie  limits  of  the  pericardium  can  be  ascer- 
tained with  great  accuracy  by  percussion  and  auscultation, 
and  this  should  always  l)e  done  l)efore  puncturing.  At  the 
jiiaiit  selected  for  puncture  the  pulsations  of  the  heart  should 
be  imperceptible,  or  at  least  very  faint,  and  it  should  be  abso- 
lutely flat  on  percussion.  It  should  also  be  remembered 
that  the  internal  mammary  artery  runs  parallel  to  the  side 
of  the  sternum,  and  a  fingers  breadth  from  it. 

If  the  knife  is  used  the  tissues  must  be  divided  layer  by 
layer,  and  the  finger  should  always  be  introduced  into  the 
wound  before  the  pericarilium  itself  is  incised,  to  make  sure 
that  the  heart  is  not  in  ontact  with  it. 


CHAPTER    VI. 

OPERATIONS  UPON  THE  ABDOMINAL  WALL.   STOMACH,  AND 

INTESTINES. 

PARACENTESIS  OF  THE  ABDOMEN. 

In  order  to  avoid  injurj'  to  the  different  viscera,  and  espe- 
cially to  the  internal  epigastric  artery,  which  rims  from 
the  middle  of  Poupart's  ligament  toward  the  umbilicus,  the 
puncture  should  be  made  either  in  the  median  line  midway 
between  the  umbilicus  and  the  symphysis  pubis,  or  midway 
between  the  umbilicus  and  the  anterior  superior  spine  of 
the  ilium.  The  instrument  used  is  a  trocar  and  canula  or 
the  needle  of  an  aspirator.  The  depth  to  which  it  shall  be 
allowed  to  penetrate  is  regulated  by  the  finger  placed  upon 
its  side,  and  it  should  be  plunged  in  sharply,  without  a  pre- 
liminary incision,  at  the  selected  point,  which  should  be 
absolutely  flat  upon  percussion.  As  there  is  a  possibility  of 
syncope  occurring  during  the  operation,  in  conse(|uence  of 
the  witlidrawal  of  pressure,  it  is  prudent  first  to  pass  a  broad, 
manv-tailed  flannel  banda*:e  about  the  abdomen,  crossino; 
its  ends  behind,  so  that  an  assistant  standing  at  each  side 
can  draw  upon  them  and  tighten  the  bandage  as  the  liquid 
escapes.     It  is  usually  sufiicient.  however,  to  have  an  assist- 


GASTROTOMY    A  N  1)    GASTROSTOMY.  387 

ant  make  sttady  pressure  with  one  liaiid  on  each  side  of  the 
iihdouien.  During  the  operation  the  patient  should  he  seated 
or  inclined  toward  one  side. 

Shouhl  heniorrliage  ensue,  tlie  attenij»t  must  first  he  nia(h.' 
to  control  it  hy  tlie  pressure  of  the  canula  or  of  a  larger 
gum  catheter  introduced  through  the  puncture.  This  fail- 
ing, the  entire  thickness  of  the  ahdominal  wall  must  he 
pinched  up  and  compressed,  or,  in  extreme  cases,  an  acu- 
pressure needle  or  harelip  pin  passed  across  the  course  of 
the  bleeding  vessel  and  pressure  made  by  a  twisted  suture 
thrown  ar(^und  its  ends. 

When  it  is  necessary  to  })ractise  paracentesis  uj)on  a 
pregnant  woman,  Ollivier  recommends  the  selection  of  the 
neighborhood  of  the  umbilicus  for  the  puncture ;  Scarpa 
]n'eferred  the  left  hypochondrium.  Vel|)eau  the  left  flank. 


GASTROTOMY  AXD  GASTROSTOMY. 

The  word  gastrotornij,  which  wa^  first  used  to  indicate  an 
operation  by  which  an  incision  was  made  through  the  ab- 
dominal walls,  whether  for  the  removal  of  a  tumor,  the 
relief  of  strangulation  of  the  intestines,  or  the  opening  of 
the  stomach,  is  now  generally  restricted  to  the  latter,  that 
is,  to  an  opening  made  through  the  abdominal  wall  into  the 
cavity  of  the  stomach.  When  the  opening  is  made  a  per- 
manent one,  the  term  (jastrostomy  {yacrfjp  stomach,  and 
GToua  mouth)  is  used.  Laparotomy  (?.o-dpa  the  flank),  a 
tenn  originally  applied  to  the  operation  for  the  relief  of 
lumbar  hernia,  is  now  tjenerallv  substituted  for  sastrotomy 
in  the  sense  formerly  given  to  that  word,  to  indicate  an  in- 
cision through  the  abdominal  walls.  It  is  sometimes  used 
in  combination,  also,  as  laparo-enterotomy, — ileotomy, — 
typhlotomy, — colotomy,  to  indicate  incision  of  the  large  or 
small  intestine,  but  the  use  of  the  terms  enterotomy  and 
colotomy  in  this  sense  is  much  more  general. 

The  operation  of  gastrotoray,  the  earliest  recorded  ex- 
ample of  which  dates  back  to  the  first  half  of  the  seven- 
teenth century,  has  been  a  very  successful  one.     Of  thirteen 

29 


338      OPERATIONS   UPON'    A  B  D  0  M  I  X  A  L   W  ALL,  ETC, 

cases  collected  bv  various  writers^  only  one  terminated 
fatally,  and  in  that  case  the  cause  of  death  is  not  known. 
Gastrostomy,  on  the  other  hand,  is  a  much  more  recent  and 
very  fatal  operation.  The  editor  of  the  Gazette  Hehdo- 
madaire.  May,  1870,  mentions  twenty-two  cases,  all  of 
which  terminated  fat<allv.  This  discourao^inor  series  has 
since  been  broken  by  A^erneuils  successful  case,  reported 
in  the  same  journal  October  27,  1>'70,  but  this  again  was 
fallowed  bv  two  fatal  ones,  one  bv  Callender,  the  other  bv 
Lannelongue ;  perhaps  the  latter  of  these  should  be  classed 
as  a  success,  for  the  patient  survived  the  operation  twenty- 
six  days  and  died  asphyxiated  in  consequence  of  the  per- 
foration of  a  bronchus  by  the  cancer,  which  occupied  the 
oesophagus  and  led  to  the  operation.  As  the  operative 
methods  are  essentially  the  same  in  both  operations,  the 
cause  of  this  difference  in  result  must  be  soucrht  elsewhere : 
and  it  is  not  difficult  to  find.  While  gastrotomy  has  always 
been  undertaken  for  the  purpose  of  removing  a  foreign  body 
fi'om  the  stomach  of  a  healthy  person,  gastrostomy  has  been 
performed  as  a  last  resource  upon  individuals  reduced  by 
starvation  and  usually  in  a  condition  of  cachexia  produced 
by  malignant  disease.  In  twenty  of  the  twenty-three  fatal 
cases  the  oesophagus  was  obstructed  by  cancer  ;  in  the  re- 
maininc:  three  the  stricture  was  traumatic,  but  of  doubtful 
nature :  in  Verneuil's  successful  case  the  stricture  was 
traumatic  :   in  Lannelonixue's  it  was  cancerous.^ 

When  the  stomach  is  distended,  it  is  in  contact  with  the 
anterior  abdominal  wall  over  quite  a  large  area  below  the 
left  lobe  of  the  liver  :  when  it  is  empty,  this  area  of  contact 
becomes  very  small,  and  lies  between  the  left  lobe  of  the 
liver  and  a  transverse  line  drawn  at  the  level  of  the  anterior 

'  Eleven  of  these  are  given  with  details  in  an  article  by  Dr.  Pooley, 
in  the  Richmond  and  Louisville  Med.  Journal,  April,  1875. 

2  In  1882  I  collected  {Medical  Record,  Nov.  1882,  p.  G65)  93  cases 
of  gastrostomy  for  obstruction  of  the  oesophagus,  of  which  18  were 
cicatricial  with  8  deaths,  and  75  cancerous  ;  of  the  latter  54  died  within 
three  weeks  after  the  operation,  and  20  survived  for  periods  varying 
from  three  weeks  to  eight  months,  two  or  three  being  still  alive  at  the 
date  of  the  last  report.  The  influence  of  the  enfeebled  condition  pro- 
duced \)\  cachexia  and  starvation  upon  the  result  is  so  marked  that 
if  the  operation  is  to  be  done  at  all  it  should  be  done  as  early  as  is 
practicable. 


r,  AST  KOTO  M  Y     AND    (}  A  ST  li  O  STO  M  V  .  ;530 

Olid  of  the  liiiilh  rib.  The  guide  to  tliis  line,  as  Tillaiix'  lias 
shown,  is  the  anterioi"  end  of  the  tenth  rih,  which  eaii  he 
readily  folt  ])rojecting  beyond  the  Imrdcr  of  the  eartihi;^es 
of  the  false  ribs,  and  ean  be  made  to  yield  a  sort  of  friction 
sound  by  rubbing  it  against  the  ninth.  Sedillot"  claimed 
that  when  the  stomach  was  em))ty,  it  was  nowhere  in  contact 
with  the  anterior  abdominal  wall,  being  separated  from  it  by 
the  liver  and  transverse  colon,  and  recommended  that  it 
should  be  ai)proached  by  a  crucial  incision  through  the  left 
rectus  muscle  two  or  three  inches  below  the  xiphoid  appen- 
dix of  the  sternum.  He  ])assed  his  fin<)jer  alon-i;  the  border 
of  the  left  lobe  of  the  liver  to  the  diaphragm,  encountered 
the  stomach  there,  seized  it  with  pronged  forceps  intro- 
duced along  the  finger,  and  drew  it  up  to  the  incision  while 
pressing  the  colon  downward.  Although,  as  stated,  more 
recent  investigations  have  shown  that  the  normal  stomach 
when  empty  is  still  in  contact  with  the  anterior  abdominal 
wall,  these  directions  for  finding  the  stomach  may  be  useful 
in  cases  where  it  has  been  drawn  back  and  bound  down  to 
the  posterior  wall  by  inflammatory  adhesions  or  neoplasms. 

The  place  at  which  the  incision  should  be  made  into  the 
stomach  itself,  is  determined  in  gastrotomy  somewhat  by  the 
position  of  the  foreign  body  within  the  viscus ;  in  gastros- 
tomy it  should  lie  midway  between  the  greater  and  lesser 
curvatures,  and  at  the  junction  of  the  cardiac  and  pyloric 
portions.  This  junction  is  often  rendered  plainly  visible  by 
an  annular  narrowing  of  the  stomach  at  that  point,  and  in 
any  case  can  be  readily  determined  by  its  distance  from  the 
pylorus,  which  can  be  reached  with  the  finger.  The  curva- 
tures can  be  recognized  by  the  vessels  running  along  them. 

Anaesthesia  is  usually  employed,  although  a  serious  objec- 
tion to  its  use  in  gastrostomy  is  found  in  the  vomiting  which 
it  is  so  likely  to  cause,  and  the  consequent  tearing  out  of  the 
sutures  uniting  the  stomach  to  the  abdomen.  Possibly  local 
anncsthesia  by  cocaine  would  be  sufficient. 

The  external  incision  is  the  same  for  both  operations. 
The  incision  made  in  the  wall  of  the  stomach  should,  in  gas- 
trotomy, be  only  large  enough  to  permit  the  removal  of  the 

'   Anatoinie  Tcpoi^rapliifjue,  p.  T'Jl'. 
'^  Mod.  Ojerat.,  vol.  ii.  j).  274, 


o40      OPERATIONS  UPON   ABDOMINAL   WALX,  ETC. 

foreign  body  ;  if  this  is  small,  the  elasticity  of  the  parts  and 
the  mobility  of  the  mucous  meml)rane  may  be  sufficient  to 
close  the  opening,  and  prevent  the  subse({uent  escape  of  the 
contents  of  the  stomach,  but  in  most  cases  one  or  more 
sutures  will  be  necessary.  Sedillot  used  a  continuous 
suture,  and  brought  the  end  out  through  the  abdominal 
wound,  which  was  then  closed  with  interrupted  sutures  ;  he 
found  no  difficulty  in  withdrawing  the  thread  a  few  days 
later.  A  silver  or  catgut  suture  applied  according  to  one 
of  the  methods  hereinafter  described  under  the  head  of 
suture  of  the  intestines,  with  both  ends  cut  short,  would  now 
be  preferred.  Labbe  united  the  sides  of  the  incision  in  the 
stomach  to  those  of  the  incision  in  the  abdominal  wall,  and 
allowed  the  gastric  fistula  thus  created  to  close  spontaneously. 
Operatio7i. — An  incision,  from  one  and  one-half  to  two 
inches  in  length,  is  made  parallel  to,  and  half  an  inch  on  the 
inner  side  of,  the  cartilages  of  the  left  false  ribs  ending 
below  at  the  level  of  the  base  of  the  cartilage  of  the  ninth 
rib,  Avhich  corresponds  to  the  depression  that  can  be  felt  just 
above  the  point  of  the  tenth  rib  (Fig.  206).     The  incision 


Fig.  208. 


Anatomical  relations  of  the  stomach  with  reference  to  gastrotomy. 

is  carried  down  layer  by  layer,  and  the  peritoneum  divided 
upon  a  director.  The  stomach  is  recognized  just  below  the 
left  lobe  of  the  liver  by  its  white  color,  smooth  surface,  and 
the  arrangement  of  its  arteries.  If  it  does  not  present  in 
the  wound,  it  must  be  sought  for  by  passing  the  finger  along 
the  border  of  the  liver,  and  pressing  the  transverse  colon 
downward. 

When  the  stricture  is  close  the  stomach  and  intestines  are 
usually  empty   and  the  abdomen  deeply  sunken  by  atmos- 


1,A  I'AUOTOMY,    A]{I)OMINAL    SKCTlON.  341 

plieric   prcssurr.      li»  such  cases,  when   each  successive  layer 

is  divided  it  rises  from  the  underlyiii;^'  mass,  and  when  the 

peritoneum   is  opened  the  air   ruslivs  in  .ind   the  ;il»dominal 

wall  i-ises  away  iVom  the  stomach  and  hccomes  level  with  the 

sternum  and  cartila;ies  of  the  ribs. 

When  found,  the  stomach  is  seized  with  })ronged  forceps, 

and  drawn  up  into  the  ahdominal  wound.     At  this  sta<^e, 

Verneuil  secured  the  stomach  by  transfixing  its  wall  with 

two  long  acupressure  needles  crossing  the  cutaneous  wound 

at  riii;ht  anirles,  incised  it,   and  fastened  the  ed^es  of  the 

...  .  ~ 

two  incisions  together  with  fourteen  silver  sutures.      Labbe, 

before  opening  the  stomach,  fastened  it  to  the  abdominal 

wall  by   eight  silver  sutures   passed  by  means  of   sharply 

curved  needles,  which  were  made  to  transfix  the  abdominal 

wall  nearly  half  an  inch  from  the  edges  of  the  incision.     By 

this  means  the  two  peritoneal  surfaces,  visceral  and  parietal, 

adjoining  the  incisions  were  maintained  in  contact,  and  their 

immediate  union  favored. 

Peritonitis  threatened  in  Labbe's  case,  but  was  checked 
by  the  application  of  a  thick  layer  of  collodion  over  the 
entire  abdomen,  immobilizing  the  latter  so  completely  that 
the  respiration  became  purely  supra-costal. 

The  method  now  in  favor  in  gastrostomy  is  to  stitch  the 
parietal  peritoneum  to  the  skin  all  around  the  incision,  and 
then  to  fasten  the  unopened  stomach  in  the  w^ound  by  several 
sutures  which  traverse  its  muscular  coat  but  do  not  enter  its 
cavity,  and  whose  deeper  ends  then  transfix  the  abdominal 
wall.  This  gives  a  broad  surface  of  contact  between  the 
peritoneum  of  the  stomach  and  that  of  the  abdominal  wall, 
and  favors  their  prompt  union.  The  protruding  portion  of 
the  stomach  may  also  be  transfixed  with  two  long  pins  which 
rest  upon  the  skin  and  prevent  strain  on  the  sutures.  The 
opening  of  the  stomach  is  delayed  as  long  as  possible,  from 
one  to  eight  days.  If  necessary,  food  can  be  introduced  by 
puncturing  with  an  aspirating  needle. 


LAPAROTOMY,  ABDOMINAL  SECTION  ((USTROTOMY). 

Laparotomy  may  be  undertaken  for  the  relief  of  occlusion 
of  the  intestines,  or,  as  in  the  case  reported  by  Dr.  Samuel 

29* 


342      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

White,  of  Hudson,  N.  Y.,  in  1S0<J.^  for  the  removal  of  a 
forei^rn  body  from  the  small  intestine  or  as  a  part  of  opera- 
tions upon  the  contents  of  the  abdomen.  When  the  nature 
and  seat  of  the  obstruction  can  be  determined  beforehand, 
and  especially  in  cases  of  intussusception,  as  Dr.  Sands  has 
shown.-  the  operation,  if  not  too  long  delayed,  offers  a 
reasonable  chance  of  success ;  but  in  chronic  invagination, 
and  when,  the  cause  and  position  of  the  obstruction  being 
unknown,  the  chances  of  finding  it,  or  of  relieving  it  when 
found,  are  very  slight,  and  the  dangers  of  laparotomy  very 
great,  Xelaton's  operation  of  enterotomy  should  be  pre- 
ferred. An  exception  to  this  preference  for  enterotomy 
must  be  noted  in  those  rare  cases  Avhere  the  obstruction 
is  situated  very  high  up,  probably  near  the  duodenum  :  for 
then  the  portion  of  intestine  above  the  obstruction  will  not 
be  able  to  absorb  sufficient  food,  even  if  it  is  lonfr  enoucrh  to 
permit  of  the  establishment  of  an  artificial  anus  in  the  groin. 
In  such  a  case  any  surgical  interference  must  be  directed 
to  the  immediate  removal  of  the  obstruction. 

Operation. — The  point  for  making  the  incision  may  some- 
times be  determined  by  the  position  of  the  obstruction  or 
the  foreign  body,  but  in  most  cases  it  should  be  made  in  the 
median  line  below  the  umbilicus.  After  havincr  recognized 
the  peritoneum  and  divided  it  upon  a  director,  a  finger  should 
be  introduced,  and  the  obstruction  sought  for.  In  the  case  of 
an  intussusception,  the  invaginated  portion  should  be  gently 
withdrawn  :  if  any  difficulty  is  experienced  in  accomplishing 
this,  the  loop  should,  if  possible,  be  brought  out  through  the 
incision,  and  disinvagination  effected  by  pulling  the  outer 
or  ensheathing  layer  downward,  and  squeezing  back  the 
lower  end  of  the  intussusceptum.  If  the  invagination  can- 
not be  reduced,  or  if  it  is  found  to  be  gancrrenous,  it  has 
been  proposed  to  excise  it,  and  unite  the  divided  ends  of 
the  intestine  by  sutures,  or  to  insert  the  upper  end  into  the 
caecum,  and  close  the  lower  end  with  a  ligature.  Leichten- 
stern^  has  collected  three  cases  of  the  latter  operation,  only 
one  of  which  was  successful. 

^  EepuLlished  in  Ayner.  Joiirn.  of  Med.  Sciences^  July,  1876,  p.  279. 
2  In  a  valuable  paper  upon  The  Treatment  of  Intussusception  by 
Abdominal  Section,  N.  Y.  Med.  Journ.^  .June,  1877. 
'  Zierassen's  Cyclopaedia,  Xew  York,  vol.  vii.  p.  662. 


RIGHT    INGUINAL    KNTKROTOMY.  343 


KiLlin    lN(aiNAh  E.NTEKOTUMV  (nKLATO.NS  OPERATION). 

As  long  ago  as  181^,  it  was  proposed  to  cstablisli  an 
artifiriiil  anus  in  tlie  ileum  in  ease  the  intestinal  ohstruetion 
could  not  l)e  found  or  removed  by  la})arotomy;  but  ^^'elaton 
was  the  first  (1840)  to  substitute  this  for  the  other  opera- 
tion, giving  up  the  search  after  the  obstruction  entirely. 
His  theory  was  that  many  obstructions  would  relieve  them- 
selves in  time,  if  a  temporary  outlet  should  be  furnished  to 
the  accumulation  above  j  in  some  cases,  on  the  other  hand, 
where  the  o])struction  is  permanent,  an  artificial  anus  in  the 
ileum  meets  the  ''vital  indication"'  perfectly — for  example, 
when  the  obstruction  is  in  the  lower  portion  of  the  small 
intestine :  while  in  others,  again,  where  the  occlusion  occurs 
below  the  ileo-cjecal  valve,  and  the  relief  afforded  would, 
conse«iuently,  be  imperfect,  the  obstruction  is  usually  due 
to  malignant  disease,  which  in  itself  would  soon  destroy 
life,  and  against  which  neither  laparotomy  nor  any  other 
operation  would  avail. 

It  is  also  essential  to  the  proper  nourishment  of  the  patient 
that  the  greater  part  of  the  small  intestine  should  remain 
serviceable :  that  is,  that  the  opening  should  be  made  in  the 
lower  part  of  the  ileum.  Of  course,  this  cannot  be  accom- 
plished when  the  obstruction  is  situated  high  up,  but,  in 
other  cases,  Nelaton  found  that  the  intestinal  loops  nearest 
the  obstruction  always  occupied  the  right  iliac  fossa,  and 
he,  therefore,  cut  through  the  abdominal  wall  just  above 
the  outer  half  of  Poupart's  ligament  on  the  right  side,  and 
opened  the  first  loop  that  presented  in  the  incision.  The 
portion  of  the  intestine  below  an  obstruction  is  ahvays  empty 
and  shrunken,  and  does  not  come  into  contact  with  the  ante- 
rior abdominal  wall,  so  that  there  is  no  danger  of  making 
the  opening  in  it  by  mistake.  It  occasionally  happens  when 
the  obstruction  is  situated  in  the  colon,  that  the  distended 
caecum  fortunately  presents  in  the  incision,  and  the  artificial 
anus  is  established  below  the  ileo-caecal  valve. 

Th*'  operation  is  simjJe  (Fig.  207).  Make  an  incision 
parallel  to  and  about  an  inch  above  Poupart's  ligament, 
beginning  at  the  anterior  superior  spine  of  the  ilium,  and 
ending  opposite  the  internal    inguinal   ring.      Divide  the 


344      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

tissues  layer  by  layer,  open  the  peritoneum  upon  a  director 
for  one  and  one-half  inches,  and  fasten  the  intestinal  loop 
which  presents  in  the  opening  to  the  abdominal  wall,  first 
by  a  wire  suture  at  each  end  of  the  incision,  and  then  by 
two  or  three  others  on  each  side.  Open  the  intestine  by  a 
longitudinal  incision  between  the  two  rows  of  sutures.  The 
sutures  should  not  include  the  skin,  and  are  best  placed  by 
means  of  a  sharply  curved  needle,  which  is  first  passed  into 

Fig.  207. 


V;^--- 


Eight  inguinal  enterotomv.     Nelaton. 


the  intestine,  and  then  brouglit  out  through  it  and  the  deep 
edge  of  the  incision.  By  this  means  the  peritoneal  surfaces 
are  kept  so  closely  in  contact,  that  when  the  intestine  is 
opened  its  contents  cannot  make  their  way  into  the  i:)eri- 
toneal  cavity.  Or  the  parietal  peritoneum  may  first  be 
drawn  out  and  stitched  to  the  skin,  as  recommended  in 
gastrostomy,  q.  v. 

For  description  of  the  operation  by  which  the  continuity 
of  the  intestine  may  be  restored  in  cases  in  which  the  occlu- 
sion is  ultimately  relieved,  see  Closure  of  Artificial  Anus, 
p.  348. 


COLOTOMY.  345 


COI.OTOMV. 

The  colon  may  bo  opened  in  its  asoendin*^  or  doscendinjr 
portions  by  an  incision  in  tlie  kunbar  region  not  invoh  ijiir 
tbe  peritoneum,  or  at  tlie  sigmoid  flexure  by  an  incision  in 
the  left  inguinal  region  opening  the  peritoneal  cavity.  The 
latter  is  known  as  Littre's  operation  or  inguinal  colotoiny, 
the  former  as  Calliscns  or  Amussats,  or  as  lumbar  colotomy. 
Littre's  operation,  for  a  long  time  almost  entirely  superseded 
by  the  other,  except  in. cases  of  imperforate  anus,  should,  I 
think,  be  generally  preferred  to  it  because  of  its  greater  ease 
and  certainty  of  execution,  and  e(j[ual,  if  not  greater,  safety. 
The  dread  of  opening  the  peritoneal  cavity,  which  led  to  the 
invention  of  lumbar  colotomy,  and  gave  it  its  vogue,  has 
been  greatly  diminished  by  antiseptic  methods. 

Littres  Colotomy ^  Inguinal  Colotomy. — Huguier  asserted 
that  the  sigmoid  llexure  in  infants  is  very  long,  and  is  to  be 
usually  found  in  the  right  iliac  region,  but  more  recent  in- 
vestigations have  shown  this  position  to  be  an  infrequent 
abnormality :  consequently  the  intestine  must  still  be  sought 
for  on  the  left  side,  as  Littre  recommended.  An  incision, 
one  inch  in  length,  is  made  parallel  to  and  a  little  above  the 
outer  half  of  Poupart's  ligament,  and  the  tissues,  including 
the  peritoneum,  divided  layer  by  layer.  The  sigmoid  flexure, 
which  can  be  recognized  by  its  irregular  lobulated  surface 
and  its  frinsre  of  fat,  is  then  soutrht  for,  drawn  into  the 
wound,  fastened  to  its  edges,  and  opened  in  the  manner 
described  under  Right  Inguinal  Enterotomy. 

In  the  adult  the  incision  should  be  from  two  to  three 
inches  long.  The  sigmoid  flexure  can  be  readily  secured  by 
passing  the  finger  through  the  incision  along,  and  constantly 
in  contact  with,  the  iliac  fossa,  the  peritoneal  lining  of  which 
is  reflected  to  form  the  mesocolon.  AVhen  the  finger  reaches 
the  intestine  it  should  be  hooked  over  it,  and  can  then  easily 
draw  it  forward.  Ordinarily  the  flexure  presents  spontane- 
ously in  the  incision. 

If  the  need  is  not  j)ressing,  the  opening  of  the  intestine 
may  be  deferred  for  a  few  days. 


346      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

Lumbar  Colotomy. — This  operation  was  first  suggested 
by  Callisen,^  in  1797,  as  a  substitute  for  Littre's,  with  a 
view  to  avoidino;  the  danc^ers  incidental  to  an  incision  throu(»;h 
the  peritoneum.  He  proposed  to  open  the  descending  colon 
in  the  posterior  third  of  its  peripher}^,  Avhere  it  is  not  covered 
by  peritoneum.  So  far  as  known,  Amussat  was  the  first  to 
perform  the  operation  in  18ol>,  and  although  he  opened  the 
ascending  colon,  and  by  a  transverse  instead  of  a  vertical 
incision,  the  operation  was  essentially  the  same  as  that  pro- 
posed by  Callisen.  All  that  portion  of  the  descending  colon 
wdiich  lies  above  the  crest  of  the  ilium  is  usually  uncovered 
by  peritoneum  on  its  posterior  aspect,  and  although  the 
actual  breadth  of  the  uncovered  portion  varies  w^ith  the 
degree  of  distention  of  the  bowel,  it  usually  amounts  to  one- 
third  of  the  entire  circumference,  and  is  bounded  on  each 
side  by  one  of  the  three  longitudinal  bundles  of  unstriped 
muscle  characteristic  of  the  colon.  In  position  it  corre- 
sponds nearly  to  the  outer  border  of  the  quadratus  lumbo- 
rum,  and  very  exactly  to  a  vertical  line  drawn  a  full  half 
inch  behind  the  centre  of  a  transverse  one,  uniting  the 
anterior  and  posterior  superior  spines  of  the  ilium  (Mason). 
On  the  right  side  (ascending  colon)  the  uncovered  portion 
is  more  often  smaller,  and  the  existence  of  an  actual  meso- 
colon, although  rare,  is  yet  more  frequent  than  upon  the  left 
side. 

Callisen  proposed  a  vertical  incision  a  little  external  to 
the  outer  border  of  the  erector  spim^  ;  Amussat  made  a 
transverse  one  midAvay  between  the  last  rib  and  the  crest  of 
the  ilium,  while  Baudens  and  Bryant  used  an  oblique  one 
passing  downward  and  outward  at  an  angle  of  45°.  The 
latter  is  to  be  preferred,  because,  while  giving  sufficient 
room,  it  inflicts  less  injury  upon  the  vessels  and  nerves  of 
the  parts,  the  general  direction  of  which  is  the  same  as  that 
of  the  incision. 

The  operation  is  performed  as  folloAvs :  The  patient  is 
etherized,  and  placed  in  a  position  midway  between  the  prone 
and  right  lateral,  a  hard  cushion  being  placed  under  the  left 
side  of  the  abdomen  to  raise  and  su})port  it.     INIason^  says 

^  Erskine  Mason,  Six  Cases  of  Lambar  Colotomy,  Am.  Journ.  of 
Med.  Sciences,  Oct.  1873. 
^  Loc.  cit. 


rOI.OTOMY.  .^47 

tlie  opt'nition  lias  hccn  ixM-fonncd  with  llic  |)Jiti('iit  seated 
and  Icaiiiiiir  forward  over  the  back  of  another  chair,  local 
anaesthesia  being  obtained  by  means  of  the  etlier  spray. 
The  anterior  and  posterior  superior  spines  of  the  left  ilium 
are  then  recoixnized,  and  a  vertical  line  drawn  u])ward  from 
a  point  one-lialf  to  three-( quarters  of  an  inch  behind  the 
centre  of  a  transverse  line  drawn  from  one  to  the  other. 
This  vertical  line  should  be  marked  with  iodine  or  nitrate  of 
silver,  in  order  to  serve  as  a  guide  during  the  operation. 

If  the  occlusion  of  the  intestine  has  not  been  complete, 
and  there  is  reason  to  ^suppose  that  the  colon  will  be  found 
empty,  it  may  now  be  distended  by  injecting  air  or  water 
through  the  rectum.  Mason  prefers  air,  and  gives  good 
reasons  for  the  preference. 

A  transverse  or  an  obli(pie  incision  four  or  five  inches  long 
is  then  made,  its  centre  lying  in  the  vertical  line  above  men- 
tioned midway  between  the  last  rib  and  the  ilium.  The 
underlying  tissues  are  recognized  and  divided  layer  by 
layer,  until  the  fascia  transversalis  and  (piadratus  lumbo- 
rum  are  reached.  The  former  is  next  carefully  divided, 
and,  if  the  adipose  tissue  covering  the  colon  does  not  then 
appear  in  the  wound,  the  latter  should  be  enlarged  on  the 
inner  side  by  dividing  the  outer  fibres  of  the  quadratus. 
The  intestine  must  always  be  sought  for  in  the  angle  of  the 
wound  nearest  the  spine,  and  whenever  it  is  desired  to  in- 
crease its  exposed  area  this  must  be  done  in  the  same  direc- 
tion. Bleeding  should  be  arrested  as  it  occurs,  certainly 
before  the  intestine  is  opened. 

The  colon  can  usually  be  recognized  by  its  distention  and 
greenish  hue,  and  possibly  by  one  of  its  longitudinal  bands. 
Additional  light  may  be  thrown  upon  the  correctness  of  the 
recognition  by  noticing  whether  the  supposed  colon  corre- 
sponds exactly  to  the  vertical  line  marked  upon  the  skin, 
and  whether  or  not  it  moves  up  and  down  with  the  acts  of 
inspiration  and  ex})iration,  for  while  the  small  intestine  has 
this  motion  the  lumbar  colon  has  it  not. 

Two  stout  ligatures  are  next  passed  by  means  of  curved 
needles  througli  the  presenting  portion  of  intestine,  and  used 
to  draw  it  up  into  the  wound,  and  fasten  it  to  the  skin  at 
the  sides  of  the  incision.  The  wound  is  then  filled  with 
sponges  or  lint,  and  the  bowel  opened  by  a  longitudinal  or 


848      OPERATIONS   UPON   AJSDOMINAL  WALL,  ETC. 

crucial  incision.  As  soon  as  the  discharge  lias  ceased,  the 
sponges  or  lint  are  withdrawn,  the  parts  cleaned,  the  extre- 
mities of  the  te2:umentarv  wound  closed  Avith  silver  sutures, 
and  the  edges  of  the  opening  in  the  intestine  made  fast  to 
the  skin  with  a  few  sutures  of  fine  silk. 


CLOSURE  OF  AN  ARTIFICIAL  ANUS  OR  FECAL  FISTULA. 

I  When  the  opening  into  the  intestine  is  small  and  the 
communication  hetween  the  portions  of  the  canal  lying 
above  and  below  it  is  free,  the  fistula  will  ordinarily  close 
spontaneously,  or  after  one  or  two  applications  of  a  caustic 
or  cautery.  But  when  the  opening  is  larger,  the  remaining 
portion  of  the  wall  of  the  intestine  is  pressed  forward  into 
it,  and  forms  a  sort  of  valve  or  spur  which  prevents,  more 
or  less  completely,  the  descending  current  of  feces  from 
entering  the  lower  segment  of  the  bowel,  and  turns  it  out 
through  the  opening  on  the  surface.  This  spur  must,  there- 
fore, be  removed  before  an  attempt  to  close  the  external 
orifice  -is  made.  This  is  best  accomplished  by  means  of 
Dupuytren's  enterotome  (Fig.  208),  or  some  similar  instru- 

FiG.  208. 


Dupuytren's  entomtomo. 

ment,  which  by  steady  pressure  upon  the  spur  provokes 
adhesion  between  its  o])posing  peritoneal  surfaces,  and  cuts 
through  it  in  four  or  five  days. 

After  the  channel  has  been  reestablished,  the  external 
orifice  may  be  closed.  If  paring  of  the  edges  and  approxi- 
mation   by  sutures  do  not    suffice,    more  elaborate   plastic 


SUTURK    OK    THK     INTKSTINP^S.  349 

motliods  must  be  ciiiploytMl.  Tlic  listiiloiis  tract  lictwceii 
the  intestine  and  the  skin  is  lined  in  ni(jst  eases  with  niiieous 
membrane,  wliieh  must  be  dissected  up  ahnost  to  the  peri- 
toneum, turned  inward,  and  its  raw  surfaces  united  with 
sutures.  Liberatinir  incisions  are  then  made  tlirough  the 
skin  and  tendon  of  tlie  external  ()bli(|ue  (if  the  fistula  is  in 
the  groin),  the  sides  of  the  opening  pared  still  further  if 
necessary,  and  brought  togetlier.  Or  lateral  flaps  left 
adherent  at  both  ends  {lumbeaux  en  pont)  may  be  dissected  J 
up,  and  their  sides  united  to  each  other  along  the  centre  of 
the  opening. 

It  sometimes  happens  that  the  lower  portion  of  the  intes- 
tine <loes  not  communicate  with  the  fistula,  and  cannot  be 
found.  If  the  upper  portion  is  too  short  for  the  proper 
nourishment  of  the  patient,  or  if  he  is  determined  to  be  rid 
of  his  infirmity  at  any  risk,  it  mav  be  justifiable  to  seek 
for  the  lower  end,  and,  by  attaching  it  to  the  opening  beside 
the  upper  end,  make  it  possible  ultimately  to  restore  the 
continuity  of  the  canal,  and  close  the  fistula  as  above  de- 
scribed. 

In  a  case  where  the  fecal  fistula  occupied  the  right 
groin,  Maisonneuve  exposed  the  csecum  by  an  incision 
parallel  to  Poupart's  ligament,  and  one  inch  above  it,  and 
established  communication  between  it  and  a  loop  of  intes- 
tine situated  just  above  the  fistula,  by  making  a  longitudinal 
incision,  two  inches  long,  in  each,  and  suturing  their  edges 
together  with  the  peritoneal  surfaces  in  contact.  The  patient 
did  not  survive  the  operation. 

In  a  similar  case  Laugier  cut  down  upon  the  csecum, 
stitched  it  fast  to  the  edires  of  the  cutaneous  incision,  and 
then,  by  means  of  a  specially  designed  enterotome,  which 
was  kept  applied  for  seven  days,  established  communication 
between  it  and  the  small  intestine.  The  patient  died  shortly 
afterward,  before  the  fistula  had  been  obliterated,  but  the 
method  is  certainly  much  better  than  Maisonneuve  s. 


SUTURE  OF  THE  INTESTINES. 

Of  the  great  variety  of  metliods  which  have  been  pro- 
posed for  closing  wounds  of  the  intestines,  only  those  deserve 

30 


350     OPERATIONS   UPON   ABDOMINAL  WALL,  ETC. 

mention  wliicli  arc  l)ase(l  upon  tlic  j)rinci|ilc  laid  down  hy 
Jobert  of  uniting  surfaces  covered  Ity  peritoneum.  Tlie 
mucous  membrane  is  so  freely  movable  u}>on  the  muscular 
coat  that  some  surgeons  think  wounds  less  than  one-quarter 
of  an  inch  in  length  may  be  safely  disregarded,  because  the 
lack  of  correspondence  between  the  two  openings  will  pre- 
vent the  escape  of  the  contents  of  the  intestine,  and  the 
wound  will  close  spontaneously.  Prof.  Gross,^  however, 
maintains  that  any  wound,  no  matter  how  small,  is  likely  to 
be  followed  by  escape  of  feces  into  the  cavity  of  the  peri- 
toneum. On  the  other  hand,  when  the  wound  is  so  large, 
or  of  such  a  character,  that  the  surgeon  is  unwilling  to  trust 
to  a  suture,  it  must  be  attached  to  the  abdominal  wall,  as 
in  enterotomy,  and  an  artificial  anus  created,  which,  if  it 
does  not  close  spontaneously,  may  be  afterward  closed  by 
the  suroreon.  Wounds  of  intermediate  sizes  must  be  closed 
either  bv  fiistenino;  them  ao-ainst  the  abdominal  wall  so  that 
communication  between  the  interior  of  the  canal  and  the 
abdominal  cavity  will  be  closed  by  adhesion  between  the 
visceral  and  parietal  surfaces  of  the  peritoneum,  or  by  turn- 
inir  the  edires  of  the  wound  inward  and  fasteninoj  them  to- 
o-ether  with  sutures.  It  is  usual  to  classifv  the  methods 
according  to  their  applicability  to  longitudinal  or  transverse 
wounds,  although  some  of  them  may  be  used  for  either. 

Longitudinal  Wounds. — AVhen  the  wound  is  small  it 
may  be  fixed  against  the  inner  edges  of  the  abdominal 
wall  by  a  suture  passed  through  the  centre  of  its  two  sides, 
brought  out  through  the  abdominal  wound,  and  fastened  to 
the  skin  by  adhesive  plaster. 

Reybard  kept  the  edges  of  the  wound  in  contact  with 
each  other  and  with  the  abdominal  wall  by  means  of  a  small 
oval  piece  of  wood,  traversed  by  a  ligature  at  two  points 
on  its  transverse  axis,  so  that  the  loop  of  the  ligature  lay 
upon  one  side  and  its  two  ends  upon  the  other.  The  piece 
of  wood  is  placed  within  the  intestine,  its  long  axis  corre- 
sponding to  the  wound,  and  the  ends  of  the  ligature  brought 
through  the  intestine  at  a  short  distance  on  each  side  of  the 
solution  of  continuity,  and  then  by  a  single  needle  through 

^  Am.  Jour,  of  Med.  Sciences,  April,  1870. 


S  U  T  U  H  E    OK    T  H  K    1  N  T  KS'l'  INKS 


.'551 


the  alxloiniiuil  ^v.•lll  noar  tlic  cxtoi-iml  incision.  Tlic  ends  of 
tlie  liLtatiirc  arc  then  so}){irjit(Ml,  drawn  ti<:;lit,  and  tied  over 
a  roll  of  lint.  After  three  or  four  days  tlie  ligature  is  cut 
and  witlidrawn,  and  the  pieee  of  wood  is  |»ass(>d  with  the 
feces. 

Jobert  used  the  simple  interrupted  suture,  taking  the 
precaution,  however,  to  roll  the  edges  of  the  wound  inward 
so  as  to  bring  the  peritoneal  surfaces  in  contact,  lie  some- 
times cut  the  ends  short,  and  sometimes  brought  them  out 
through  the  abdominal  wound.  In  a  former  case  they  ulti- 
mately fell  into  the  intestine;  in  the  latter,  they  were  with- 
drawn on  the  fifth  or  sixth  day. 

Lembert  modified  this  by  making  the  ligatures  include 
only  a  narrow  strip  of  the  muscular  and  none  of  the  mucous 
coat  (Fig.  20t)).     A  needle  carrying  the  ligature  was  entered 


Suture  of  tlie  iutestincs.     Lembert's  method. 


on  the  outer  surface  of  the  intestine  four  millimetres  from 
the  edi-e  of  the  wound,  and  brou<i;ht  out  two  millimetres  from 
it  without  having  perforated  the  mucous  membrane,  it  was 
then  passed  in  the  same  manner  on  the  opposite  side,  and 
after  the  necessary  number  of  ligatures  had  been  thus  in- 
serted they  were  tied  and  cut  short.  The  effect  of  this 
method  of  placing  the  ligutures  is  to  roll  the  edges  of  the 
incision  inward  and  to  avoid  the  danger  of  an  escape  of  feces 
into  the  abdominal  cavity  through  an  opening  left  by  the 
fall  of  a  ligature.      The  ligatures  should  l)e  of  silver,  carbo- 

lized  silk,  or  tou^h  cato;ut. 

Ill 
Gely  used  a  long  ligature  with  a  needle  at  each  end,  and 

placed  it  as  shown  in  Fig.  210.     The  points  of  entry  should 


352      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

be  about  five  millimetres  apart.     The  needles  used  should  be 
small,  and  it  is  well  to  make  a  knot  at  each  crossing. 

Bouisson  obtained  the  same  result  by  passing  an  insect 
pin  in  and  out  along  each  side  of  the  wound,  as  shown  in 

Fig.  210. 


Suture  of  the  intestines.     Gelv's  method. 


Fig.  211,  and  drawing  them  together  laterally  by  ligatures 
passed  through  the  intervals.  One  end  of  each  ligature 
was  cut  short,  and  the  other  brought  out  at  the  loAver  angle 
of  the  external  wound ;  a  thread  was  tied  under  the  head 


Fig.  211. 


Suture  of  the  intestines.     Bouisson's  method. 


of  each  pin  and  brought  out  at  the  upper  angle  of  the 
wound.  On  the  third  or  fourth  day  the  pins  were  with- 
drawn by  means  of  tlie  threads  attached  to  them,  and  the 


SUTURE    OK    THK     INTESTINES 


353 


lijxaturc'S  havin*'    brcn    thus  frt'cd,   "wcrc  ^vitlnl^a^Mi   at   tlie 
same  time. 

BeiTnger-Feraud  used  two  strips  of  cork  six  inilliiiietres 
wide  and  thick,  and  as  hjng  as  the  wound  (Fig.  'il2,  /I). 
Each  piece  is  pierced  hy  pins  whose  points  project  five  or 
six  milliuietres  on  one  side,  and  wliose  lieads  are  sunk  in 
the  cork  and  covered  with  sealing-wax  on  the  otlier.  They 
are  then  phiced  inside  tlie  intestine,  one  on  each  side  of  the 

Fig.  212. 


Berenger-Feraud':?  metlio<l  of  closiug  a  wound  of  the  iiiteeiiue.     A.  The  strii's.     B.  The 
striiKs  in  place.     C.  The  strips  pinned  together  and  the  opening  closed. 

wound  and  parallel  to  it,  and  the  pins  forced  through  from 
within  outward  two  or  three  millimetres  from  the  edge  (Fig. 
'212,  B).  They  are  then  turned  so  that  the  points  face  each 
other,  and  the  pins  of  each  driven  into  the  other  by  pressure 
throuorh  the  sides  of  the  intestine.  The  strips  ultimately 
come  away  with  the  feces. 

Dubrueil  suggests  that  the  strips  should  be  fixed  together 
more  firmly  by  a  Ijent  pin  at  each  end,  as  represented  in 
the  figure ;  there  would  then  be  less  danger  of  their  falling 
apart  and  injuring  the  intestine  on  their  way  out. 

These  methods  have  given  place  to  antiseptic  silk  or  cat- 
gut sutures  applied  according  to  Lembert's  method  and  cut 
short. 


Tnnisvrs''  Wounds. — The  old  methods  of  uniting  a  di- 
vided intestine  end  to  end  over  a  cylinder  of  cardboard  or 

30* 


354      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

a  calf's  trachea  introduced  within  it,  or  of  simply  inserting 
the  upper  end  into  the  lower,  have  fallen  into  entire  disuse. 
The  safest  plan  in  most  cases  is  to  make  an  artificial  anus 
and  trust  to  closing  it  afterward,  but  when  that  is  not  prac- 
ticable, or  when  the  wound  is  small,  it  may  be  closed  by 
any  of  the  methods  al)ove  described,  modified  according  to 
circumstances.  Holmes^  says  it  is  entirely  justifiable,  even 
in  cases  of  total  division,  to  unite  the  edges  with  the  con- 
tinuous suture,  cut  it  short,  and  let  it  ulcerate  through  into 
the  bowel. 

Jobert  turned  the  lower  end  of  the  bowel  in  upon  itself, 
and  then  introduced  the  upper  one,  fiistening  them  together 
with  two  lis:atures  which  he  brou2;ht  out  at  the  abdominal 
wound  (Fig.  213).     AVhen  the  division  was  incomplete,  he 

Fig.  213. 


Reunion  of  intestines  divided  transversely.     A.  The  lower  end  doubled  inward  npon 
itself.     .Tobert's  method. 

used  only  one  ligature.  The  principle  of  this  method  is 
correct,  for  it  brings  two  peritoneal  surfaces  into  contact, 
but  it  may  be  difficult  to  determine  which  is  the  lower  and 
which  the  upper  end.  The  best  means  is  to  pass  the  finger 
backward  along  the  mesentery  to  its  posterior  attachment 
which,  being  fixed,  is  a  sure  guide. 


HERNIOTOMY,  KELOTOMY. 

Under  this  head  are  to  be  described  the  operations  for 
the  relief  of  strangulated  iiKjuinal^  femoral^  umhilical,  and 


'  Surgery,  its  Principles  and  Practice,  p.  237,  Philada.,  187G. 


1 1  K  K  N  1  ()  T  ()  M  Y  ,   K  K  \.i)  T  U  M  V  .  355 

ohturator  Itcrnufti,  and  those  for  the  riuhcal  cure  ot"  the  first 
tliree  varieties. 

It  has  been  well  said  that  there  is  no  operation  in  -which 
the  unforeseen  has  a  lar<j;er  share  than  in  herni(>toniy,  none 
in  which  the  surgeon  is  called  upon  to  show  more  skill, 
sagacity,  and  decision.  The  causes  of  this  are  to  be  found 
in  the  absence  of  absolute  guides  to  the  hernial  sac,  the 
changes  in  the  sac  and  overlying  tissues  ])rought  about  by 
inilainniation  or  time,  the  character  of  the  hernia — whether 
composed  of  omentum,  intestine,  cixjcum,  or  bladder,  and 
lastly,  the  difTiculty  of  iletermining  not  only  the  extent  of 
the  injury  done  to  the  strangulated  tissues,  but  even,  in 
some  cases,  the  route  taken  by  the  liernia  in  its  descent.  It 
is  desirable,  therefore,  that  the  account  of  the  different  ope- 
rations should  be  preceded  by  some  general  considerations 
upon  these  subjects. 

General  Directions.  A.  Mecognition  of  the  Sac  and 
Bowel. — The  first  difficulty  encountered  in  the  course  of 
the  operation  is  that  of  recognizing  the  sac.  The  thickness 
of  the  connective  tissue  covering  it  varies  greatly  in  different 
cases ;  each  layer  must  be  pinched  up  with  forceps,  opened 
with  the  knife  lying  upon  its  side,  as  in  opening  the  sheath 
of  an  artery,  then  raised  upon  the  finger  or  a  director,  and 
divided  to  the  full  extent  of  the  cutaneous  incision,  after 
having  been  carefully  scrutinized.  Occasionally  a  cyst 
containing  licpiid  is  found  in  front  of  the  hernia,  and  may 
at  first  be  mistaken  for  it,  for  usually  the  sac  contains  a 
certain  amount  of  serum.  Careful  examination  of  the  tissues 
before  division  is  absolutely  necessary,  because  in  those  rare 
cases  where  there  is  no  sac  (hernia  of  the  caecum  or  of  the 
bladder),  and  in  others  where  it  is  quite  undistinguishable, 
it  is  only  by  recognizing  the  muscular  coat  when  he  reaches 
it,  that  the  surgeon  avoids  oi)cning  the  intestine  or  bladder 
by  mistake.  As  the  sac  is  approached,  each  layer  should 
be  pinched  up  in  a  narrow  fold,  and  moved  gently  across 
the  underlying  parts;  if  a  smooth  globular  tumor  is  felt 
below,  the  surgeon  makes  an  opening  in  the  fold,  confident 
that  the  wall  of  the  intestine  is  not  included  in  it ;  but 
if  he  is  unable  to  pinch  up  the  fold,  or  if,  instead  of  the 
sensation  of  a  smooth  globular  mass,  he  gets  only  that  of 


356      OPERATIONS  UPON   ABDOMINAL   WALL,  ETC. 

an  empty  space,  he  examines  the  surface  again,  divides 
Avith  a  probe-pointed  bistoury  any  fibrous  bands  he  may 
find  at  the  neck  of  the  hernia,  and  tries  to  introduce  his 
finger  through  it  into  the  ab(h)minal  cavity.  If  he  succeeds, 
he  knows  tlie  sac  has  been  opened :  if  he  does  not  succeed, 
he  renews  the  examination  and  continues  the  dissection. 

Maisonneuve  said  the  surgeon  may  know  he  has  not 
reached  the  intestine  so  long  as  he  is  not  certain  of  having 
done  so ;  but  this  is  not  true  of  all  cases ;  the  intestine  is 
not  always  smooth  and  shining ;  it  may  be  dark,  dull,  con- 
gested, and  thickened,  and  in  hernia  of  the  caecum  it  may 
have  no  peritoneal  coat. 

When  the  hernia  is  small  and  recent  the  sac  is  bluish, 
and  can  be  pinched  up  between  the  thumb  and  finger,  so 
that  its  smooth  opposing  surfaces  can  be  felt  to  glide  upon 
one  another.  When  it  is  laro;e  and  of  lonor  standinor,  the 
sac  may  be  exceedingly  thin  and  unrecognizable,  or  very 
thick  and  adherent.  If  small,  it  should  be  thoroughly  iso- 
lated, and  its  boundaries  everywhere  defined ;  if  large  and 
adherent,  its  neck  alone  should  be  cleared. 

B.  Opening  of  the  Sac. — The  propriety  of  opening  the 
sac  has  long  been  a  subject  of  dispute.  The  only  objection 
to  it,  but  that  a  serious  one,  is  the  danger  of  thereby  setting 
up  peritonitis.  On  the  other  side  is  the  danger  of  returning 
the  hernia  into  the  abdomen  in  a  o;ano;renous  condition,  or 
unreduced  when  the  stricture  is  formed  by  the  sac  itself. 
Admitting  that  the  opening  of  the  sac  is  in  itself  an  evil, 
and,  therefore,  to  be  avoided  whenever  possible,  two  general 
rules  may  be  laid  down.  The  sac  should  be  opened :  1st. 
Whenever  there  is  good  reason  to  fear  that  the  bowel  is 
gangrenous,  when  there  has  been  long-continued  vomiting 
and  tenderness  on  pressure;  and  2d.  Whenever  the  hernia 
cannot  be  completely  returned  into  the  abdomen.  In  esti- 
mating; the  chances  of  iranorene,  it  must  be  remembered  that 
it  occurs  much  more  promptly  after  the  symptoms  of  strangu- 
lation appear  in  sudden  recent  hernias,  than  it  does  in  old 
ones. 

The  liquid  whicli,  as  has  been  already  mentioned,  is  usually 
contained  in  the  sac,  may  not  only  serve  to  call  attention  to 
its  accidental  opening,  but  may  also  be  taken  advantage  of 
to  open  it  safely  when  it  has  been  recognized,  and  its  open- 


HERNIOTOMY,  KELOTOMY.  357 

iiig  lias  Iteon  dotennined  upon.  It,  of  course,  collects  at  the 
most  (le{>on<k'nt  j)oiiit,  and  there  intervenes  l)et\veen  tlie  sac 
and  the  bowel,  so  that  the  former  can  he  pinched  up  and 
opened  without  injury  to  the  latter.  When  this  is  not  the 
case,  the  surgeon  must  pinch  up  a  very  small  fold  of  the  sac 
wherever  he  can  do  so,  or  do  as  Mr.  Liston  did  in  a  ca,se 
where,  as  he  says,  ''there  was  no  possibility  of  j)inching  up 
the  sac,  either  with  the  finger  or  forceps :  it  containe<l  no 
fluid,  and  was  imjiacted  most  firmly  with  bowel;  very  luckily 
the  membrane  was  there ;  and,  observing  a  pelleton  of  fat 
underneath,  I  scratched  very  cautiously  with  the  point  of  the 
knife  in  the  unsupported  hand,  until  a  trifling  puncture  was 
made,  sufficient  to  admit  the  blunt  point  of  a  narrow  bis- 
toury. "^  The  opening  should  be  enlarged  until  the  finger 
can  be  introduced,  and  then  the  sac  slit  up  on  it  as  a  guide. 
If  the  omentum  is  then  found  filling  the  sac,  it  must  be 
cautiously  cut  into,  for  it  is  probable,  especially  in  umbilical 
hernia,  that  a  strangulated  loop  of  intestine  will  be  found  in 
its  centre.  If  such  a  loop  is  found,  the  finger  must  be  passed 
alonix  the  bowel,  the  director  inserted  below  the  rinj]j  of  the 
omentum,  and  the  constriction  incised  just  sufficiently  to 
admit  of  the  return  of  the  bowel. 

C.  Division  of  the  Stricture.  —  The  left  forefinger  is 
passed  up  into  the  neck  of  the  sac  to  the  stricture,  the  pulp 
upward,  the  nail  pressing  against  the  intestines ;  if  the 
stricture  is  found  to  be  caused  by  a  fibrous  band  below  the 
neck  of  the  sac,  it  may  be  divided  freely  without  risk  ;  but 
if  it  is  situated  at  the  opening  in  the  abdominal  wall  through 
which  the  hernia  made  its  escape,  the  division  must  be  made 
with  reference  to  the  anatomy  of  the  region.  If  the  divi- 
sion cannot  be  made  at  the  desired  point,  but  only  at  some 
other  where  an  incision  of  the  necessary  extent  would  be 
dangerous,  the  stricture  must  be  slightly  nicked  at  that 
point,  and  advantage  then  taken  of  the  partial  liberation  to 
make  a  second  cut  in  the  proper  place. 

The  end  of  the  finger,  or  its  nail,  is  gently  engaged  in 
the  stricture,  its  pulp  against  the  selected  point  of  division, 
and   the  knife,  a  probe-pointed,   slightly  curved   bistoury, 

*  Op.  Surgery,  p.  402,  quoted  by  Jos.  Bell,  Manual  of  Surgical 
Operations,  p.  2:^1. 


358      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

passed  on  the  flat  along  its  palmar  surface  until  the  point 
has  passed  through  the  stricture.  The  surgeon  then  turns 
its  edge  upward  and  presses  it  against  the  stricture  with 
the  end  of  the  finger  on  which  it  rests.  A  slight  crackling 
announces  the  division,  which  must  be  extended  or  repeated 
at  different  points  until  the  finger  can  he  passed  freely 
through  into  the  abdomen. 

Instead  of  an  ordinary  probe-pointed  bistoury,  a  specially 
constructed  hernia  knife  (Fig.  :214)  is  often  used.      It  is 

Fig.  214. 


Hernia  knife. 


probe-pointed  and  its  cutting  edge  not  more  than  an  inch 
long.  The  knife  may  also  be  guided  upon  a  director  in- 
stead of  the  finger.  The  "'hernia  ehrector"  is  broader  than 
the  ordinary  one,  and  sometimes  has  a  broad  flange  on  each 
side  to  keep  the  bowel  from  rolling  over  against  the  edge  of 
the  knife. 

D.  Examination  and  Return  of  the  Bowel. — The  bowel 
should  be  gently  drawn  out  about  an  inch  in  order  that  the 
constricted  part  itself  may  be  examined,  for  it  is  very  likely 
to  1)0  badly  damaged.  If  the  entire  loop  is  in  suitable  con- 
dition it  must  be  carefully  cleaned  of  all  blood  and  gradually 
returned  into  the  cavity  of  the  al)domen.  It  is  not  always 
easy  to  decide,  however,  whether  or  not  its  condition  is  suit- 
able for  return,  and  some  surgeons  have  recommended  that 
in  cases  of  doubt  it  should  be  covered  with  w^arm,  wet  cloths 
and  kept  under  observation  for  some  time,  the  stricture,  of 
course,  having  been  previously  divided. 

A  very  great  change  in  the  color  of  the  loop  is  fiir  from 
proving  the  existence  of  gangrene.  A  deep  red,  vinous, 
even  violet  color  does  not  preclude  recovery,  especially  if 
the  surface  has  not  lost  its  lustre ;  but  if  it  is  black,  or  deep 
brown,  or  grayish-yellow,  or  if  it  is  dull,  flaccid,  or  wrinkled, 
it  is  certainly  gangrenous.      Of  course,  when  the  charac- 


HERNIOTOMY,  KELOTOMY.  ■]59 

toristic   <X!>niri'('Ti()iis  odor,  or  the  fccjil  odor  conscqiiciit   on 
perforation,  exists,  there  can  l»e  no  doiiht. 

It"  the  h)o]ts  are  in  i^ood  e(Hidition,  but  hound  fast  t(»  one 
anotlier,  or  to  the  onientiini,  or  to  the  .sac  hy  firm  adhesions, 
irreat  caution  luust  l)e  exercised  in  dealin*:;  with  them.  'IMio 
stricture  must  be  freely  divided  and  tlie  loops  emjjtied  of 
their  contents  by  pressure ;  but  the  adhesions,  which  have 
proltablv  existed  for  a  lon<r  time  without  inconvenience  to 
the  j)atient,  should  in  most  cases  be  left  undisturbed,  the 
wound  closed,  and  the  hernia  treated  as  an  irreducible  one. 

It  is  not  always  easy  to  return  the  intestines  even  after 
the  stricture  has  been  (fivided.  The  surgeon  should  try  to 
rechice  one  end  at  a  time,  by  scpieezing  its  contents  back 
into  the  abdomen  and  pushing  the  gut  in  afterward.  If  tlie 
bowel  is  very  tense  the  gas  may  be  <lrawn  off  with  a  fine 
aspirator.  If  ru})ture  occurs,  and  the  bowel  is  otherwise  in 
good  condition,  it  must  be  closed  with  the  continuous  suture 
(Holmes)  and  returned  into  the  abdomen. 

If  the  intestine  is  gangrenous,  nm  artificial  anus  must  be 
formed,  and  it  is  well  to  stitch  the  bowel  fast  to  the  edges 
of  the  hernial  ring,  as  in  enterotomy.  If  the  gangrene 
extends  to  the  point  of  stricture  and  the  bowel  cannot  be 
drawn  further  out,  the  stricture  must  not  be  divided,  lest 
the  bowel  should  slip  back  and  feces  escape  into  the  peri- 
toneal cavity.  The  gangrenous  portion  must  be  incised, 
and  then,  if  the  feces  pass  freely,  nothing  more  need  be 
done,  beyond  taking  measures  to  prevent  the  bowel  from 
slipping  back,  such  as  making  its  edges  fast  to  the  sides  of 
the  incision,  or  passing  a  stout  ligature  through  the  mesen- 
tery and  fastening  it  to  the  skin  with  adhesive  plaster.  But 
if  the  stricture  still  prevents  the  flow  of  feces,  Gosselin's 
])lan  of  dilating  it  by  introducing  the  finger  into  the  intes- 
tine should  be  adopted. 

E.  Treatment  of  tlie  Onientwn. — If  only  a  small  amount 
of  omentum  is  found  in  the  sac,  and  if  it  is  in  good  condi- 
tion, it  may  be  returned ;  but  if  there  is  much  of  it,  or  if 
it  is  inflamed,  suppurating,  or  gangrenous,  it  must  be  kept 
out.  Holmes  says  the  practice  at  St.  George's  Hospital  is 
to  transfix  its  base  with  a  stout  double  ligature  and  cut  it 
off,  bringing  the  ends  of  the  ligature  out  through  the  wound ; 


360      OPERATIONS   UPOX   ABDOMINAL   WALL,  ETC. 

some  excise  it  and  tic  all  bleeding  points,  while  others  again 
simply  leave  it  in  the  wound. 

Strangulated  Inguinal  Jleniia.  —  Inguinal  hernia  may 
be  oblique  or  direct.  The  former  leaves  the  abdomen  at  the 
internal  (deep)  abdominal  ring,  having  the  deep  epigastric 
artery  on  its  inner  side  (Fig.   21.3),  passes   down  the  in- 

FiG.  215. 


Hernia.     The  relations  uf  the  femoral  and  internal  abdominal  rings,  seen  from 
within  the  abdomen      Right  side. 

guinal  canal,  and  emerges  at  the  external  abdominal  ring 
(Fig.  210) :  the  latter  makes  its  way  through  Hesselbach's 
triangle,  a  space  bounded  by  the  epigastric  artery,  Pou- 
parts  ligament,  and  the  rectus  abdominis  muscle  (Fig. 
215),  and  also  emerges  at  the  external  abdominal  ring. 
The  former  is  by  far  the  more  common  variety,  and  the 
seat  of  stricture  is  usually  at  the  internal  abdominal  ring, 
but  sometimes  in  the  scrotum,  at  a  point  where  the  intestine 
has  forced  its  way  through  a  fibrous  septum  limiting  an  en- 
cysted hydrocele  of  the  cord.      In  the  second  variety  the 


HERNIOTOMY,  KELOTOMY. 


3<U 


stricture  may  be  at  the  external  ring  or  at  tlie  conjoined 
tendon,  the  epitrnstric  artery  lying  at  its  outer  side. 

Oprnftion. —  Tlie  parts  having  heen  well  shaved,  the 
patient  is  annesthetized  and  plaee<l  upon  his  back,  with  his 
shoulders  slightlv  raised,  thighs  flexed  and  adducte<l.  The 
surgeon  pinches  uj)  a  broad  fold  of  skin  and  subcutaneous 
tissue  across  the  long  axis  of  the  swelliuir,  transfixes  it  at 

Fig.  21^5. 


Inguinal  hernia,  showing  the  transversah's  moacle,  the  transrersalis  fa^ia,  and 
the  internal  abdominal  ring. 

its  base  with  a  straight  bistoury,  and  cuts  vertically  through 
it,  thus  dividing  most  of  the  tissues  without  danger  of  injury 
to  the  sac  or  intestine ;  if  necessary,  this  incision  must  be 
lengthened,  so  that  its  upper  extremity  will  lie  at  or  above 
the  external  abdominal  ring,  and  its  lower  extremity  below 

31 


362      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

the  bottom  of  the  hernial  sue.  The  underlying  layers  arc 
then  pinched  up  one  by  one  Avith  the  thumb  and  finger,  or 
"svith  fine  forceps,  and  divided  upon  a  director  until  the  sac 
is  reached. 

If  the  sac  is  recognized,  and  if  it  is  thought  best  not  to 
open  it,  its  limits  must  be  "well  cleared  and  defined,  unless  it  is 
very  large,  and  the  finger  passed  into  the  external  abdominal 
rino;.  If  the  rins;  is  tio-ht,  the  internal  r)illar  must  be  divided 
directly  upward  with  a  probe-pointed  knife,  all  constricting 
bands  about  the  neck  of  the  sac  raised  upon  the  director  and 
cut,  and  the  canal  and  internal  ring  explored  Avith  the  left 
forefinger.  If  the  stricture,  Avhich  is  usually  situated  at 
the  internal  ring,  is  then  found  to  be  external  to  the  sac,  it 
must  be  cautiously  nicked  directly  upward  with  a  narrow 
probe-pointed  bistoury  or  a  hernia  knife  (Fig.  214).  This 
nicking  may  be  repeated,  if  necessary,  at  one  or  two  points 
on  the  upper  and  outer  side,  until  it  becomes  possible  to 
press  the  intestines  back  into  the  abdomen.  The  sac  itself 
is  then  reduced,  unless  the  hernia  is  an  old  one,  or  adhesions 
have  formed,  and  the  wound  is  closed  with  sutures  except 
at  its  loAver  angle. 

If,  hoAvever,  the  sac  is  to  be  opened,  every  precaution 
must  be  taken  to  avoid  injury  to  the  intestines.  The  best 
point  for  opening  it  is  at  its  extreme  lower  end,  because  a 
little  serum  is  usually  collected  there,  separating  it  from 
the  boAvel.  It  must  be  pinched  up,  if  possible,  at  the  point 
selected,  and  an  opening  made  Avitli  the  knife  held  flat 
against  it ;  a  director  or  the  fino;er  is  then  passed  through 
the  opening,  and  the  full  length  of  the  sac  slit  up.  The  con- 
striction is  then  sought  for,  and,  if  found  above  the  external 
ring,  must  be  nicked  or  divided  upAvard,  as  before  described. 

If  it  can  be  positively  made  out  that  the  hernia  is  of  the 
oblique  variety,  the  cutting  should  be  done  on  the  outer  side, 
for  the  epigastric  artery  lies  close  to  the  inner  side  of  the 
internal  ring,  through  Avliich  this  variety  passes ;  and  if  it 
is  knoAvn  to  be  of  the  direct  varietv.  the  cuttino;  must  be 
done  upon  the  inner  side.  But,  unfortunately,  in  most  cases 
the  dragging  of  the  hernia  brings  the  tAvo  rings  immediately 
opposite  each  other,  so  that  the  inguinal  canal  can  no  longer 
be  said  to  exist,  and  the  diagnosis  cannot  be  made  Avitli  cer- 


HERNIOTOMY,  KELOTOMY.  363 

tainty.     The  iiu'ision  must  tlien  be  made  upward,  parallel  to 
the  course  of  the  epiirastric  artery. 

The  intestine  must  next  be  examined  to  ascertain  it'  it  is 
in  a  fit  condition  to  be  returned  ;  and  here  it  must  not  be 
foi-ijrotten  to  draw  down  an  inch  or  more  of  each  end  so  that 
the  part  wliich  has  undergone  constriction  may  also  be  ex- 
amined. If  the  condition  is  satisfactory,  the  bowel  is  re- 
turned irniduallv,  not  en  niassr,  the  sac  also,  if  free:  and 
the  wound  closed,  except  at  the  dependent  angle. 

M'(h/((n/ne.s  Method. — Malgaiirne  made  a  small  incision 
directly  over  the  supposed  seat  of  the  stricture,  and  divided 
all  the  tissues  down  to  tfie  sac.  If  a  fibrous  ring  was  the 
cause  of  the  strani^ulation,  it  would  be  divided  in  the  course 
of  the  incision,  and  the  hernia  could  then  be  reduced  without 
opening  the  sac.  If,  on  the  other  hand,  the  stricture  was 
caused  by  the  neck  of  the  sac.  he  divided  the  latter  from 
without  inward  very  cautiously,  or,  if  it  was  very  tight, 
made  a  small  opening  in  the  peritoneum  above  and  below, 
piissed  a  director  through  the  neck,  and  cut  upon  it. 

This  method  is  entirely  inapplicable  whenever  it  is  neces- 
sary to  examine  into  the  condition  of  the  bowel ;  and  the 
persistence  of  a  pouch  in  wliich  pus  can  accumulate  is  a 
great  objection  whenever  the  sac  has  to  be  opened.  The 
only  advantage  which  it  possesses  over  the  ordinary  opera- 
tion in  the  class  of  rarer  cases  where  the  stricture  is  situated 
outside  of  the  sac  is  the  comparatively  unimportant  one  of 
re([uiring  a  smaller  incision. 

Stram/ulated  Femoral  ILrnia. — ^The  intestine  in  its 
descent  occu[»ies  a  canal  which  begins  at  the  femoral  ring 
under  Poupart's  ligament,  between  the  free  arched  border 
of  Gimbernat's  ligament,  and  the  femoral  vessels  (Fig. 
215),  and  ends  at  the  saphenous  opening  in  the  fascia  lata 
of  the  thigh.  After  passing  through  the  opening  it  turns 
upward  over  the  groin.  The  normal  length  of  the  canal 
is  about  an  inch,  but  in  hernias  of  long  standing  it  is  much 
shortened  by  the  approximation  of  its  two  ends.  The  seat 
of  stricture  is  now  thought  to  lie  in  most  cases  at  the  saphe- 
nous opening,  and  not  at  the  base  of  Gimbernat's  ligament,  as 
was  formerly  supposed;  free  division  is  possible  at  the  former 
point  on  the  upper  and  inner  side  without  the  risk  of  injury 


364      OPERATIONS  UPON   ABDOMINAL   WALL,  ETC. 

to  any  organ,  except  possibly  the  spermatic  cord,  and  that 
is  at  such  a  distance  as  to  be  practically  out  of  harm's  way. 
Under  ordinary  circumstances,  Gimbernat's  ligament  can 
also  be  safely  divided  on  tlie  inner  side,  but  in  about  one  and 
one-half  per  cent,  of  cases  the  obturator  artery  pursues  the 
anomalous  course  shown  in  Fio;.  -IT,  and  then  lies  directly 


Fig.  21  ■ 


Variations  in  origin  and  course  of  obturator  artery. 

in  the  way  of  the  knife.  The  neck  of  the  sac  under  such 
circumstances  is  entirely  surrounded ;  on  its  outer  side  are 
femoral  vessels,  above  are  the  spermatic  cord  and  common 
trunk  of  the  epigastric  and  obturator  arteries,  on  its  inner 
side  the  obturator  artery,  below  it  the  bone.  The  only  safe 
plan  of  relieving  the  stricture,  therefore,  is  to  nick  it  slightly, 
to  the  depth  of  one  or  two  millimetres,  at  several  points  on 
its  upper  and  inner  borders.  The  coverings  of  the  hernia 
are  thin  and  composed  of  the  skin,  subcutaneous  tissue,  crib- 
riform fascia  sometimes,  septum  crurale,  and  peritoneum. 

The  incision  may  be  straight  or  curved,  the  convexity 
directed  downward  and  outward,  or  T-shaped,  the  hori- 
zontal branch  being  made  along  Poupart's  ligament,  the 
other  passing  directly  downward  over  the  saphenous  open- 
ing. The  horizontal  incision  should  be  made  by  transfixing 
a  vertical  fold  of  skin  and  subcutaneous  tissue  pinched  up 
between  the  thumb  and  fingers,  the  other  should  be  made 
from  withr)ut  inward.  The  underlying  tissues  must  be  di- 
vided, and  the  sac  exposed  or  opened  in  the  manner  described 
under  General  THrectionSj  and  the  seat  of  stricture  sought 
for  and  divided  according  to  the  rules  above  laid  down.  If 
the  operator  has  decided  to  perform  the  so-called  minor  ope- 
ration— that  is,  not  to  open  the  sac — the  edge  of  the  saphe- 


HERNIOTOMY,  KELOTOMY.  365 

nous  opening  must  be  carefully  exposed  and  divided  on  its 
upper  and  inner  side,  tlie  finger  passed  into  tlie  canal,  and 
()rinil)ernat'8  ligament  nicked  if  necessary. 

Malgaigne  pursued  the  same  method  as  in  femoral  hernia, 
cutting  down  upon  the  seat  of  the  stricture,  tearing  the  edge 
of  the  saphenous  opening  Avith  a  blunt  spatula  instead  of 
cutting  it,  and  not  opening  the  sac  unless  he  had  good  reason 
to  suppose  the  intestine  was  already  damaged.  It  is  par- 
ticularly unsafe  to  reduce  a  femoral  hernia  unopened ;  first, 
because  the  boundaries  of  the  canal  are  so  tough  and  un- 
yielding that  gangrene  follows  promptly  on  strangulation, 
especially  in  a  small  recent  hernia ;  and  secondly,  because 
the  reduction  may  seem  to  be  complete  wdiile  a  strangulated 
knuckle  of  intestine  still  remains  within  the  stricture. 

Strangulated  UmhiJiral  Hernia. — It  is  generally  claimed 
that  true  umbilical  hernia,  that  is,  hernia  through  the  umbi- 
lical ring,  is  almost  always  congenital,  and  that  the  hernias 
which  occur  during  adult  life  emerge,  not  through  the  ring, 
but  through  an  accidental  opening  in  the  linea  alba  near  it, 
and  therefore  deserve  the  name  of  peri-umhilical  given 
them  by  Gosselin.  While  this  condition,  that  is,  of  escape 
through  a  chance  opening  in  the  linea  alba,  may  exist  in 
some  cases,  Richet^  has  sought  to  prove  by  anatomical  con- 
siderations and  by  the  results  of  the  examination  of  three 
cases  of  hernia,  that  true  umbilical  hernia,  on  the  contrary, 
is  the  rule,  and  the  other  is  the  exception.  He  shows  that 
the  weak  point  of  the  ring  is  its  upper  portion,  and  that 
when  the  cicatrix  is  pressed  downward  and  given  a  semi- 
circular form  by  the  hernia,  a  complete  ring,  which  seems 
to  be  situated  above  that  corresponding  to  the  vein  and 
arteries,  is  constituted  by  the  cicatrix  below  and  the  upper 
part  of  the  opening  above,  and  exactly  resembles  a  distended 
accidental  perforation. 

The  peritoneum  is  much  more  adherent  to  the  abdominal 
wall  in  the  umbilical  than  it  is  in  the  inguinal  region,  and, 
consequently,  the  sac  of  a  hernia,  being  formed  by  the  dis- 
tention of  a  small  portion  of  peritoneum,  is  exceedingly  thin, 
in  fact  its  existence  has  been  denied.     The  coverings  of  the 

*  Anatomic  Medico-Chirurgicale,  Part  II.  p.  378. 
31* 


366      OPERATIONS  UPON  ABDOMINAL   WALL,  ETC. 

hernia  are  the  skin,  ceUular  tissue,  and  peritoneum  ;  its 
contents  are  the  small  intestine,  sometimes  the  transverse 
colon,  and  in  the  adult  the  omentum. 

The  results  of  kelotomv  in  umbilical  hernia  have  been  so 
unfavorable  that  Huguier  proposed  the  operation  should  be 
restricted  to  recent,  small  hernias  which  were  previously 
reducible,  and  that  all  others  should  be  left  entirely  to  them- 
selves, or  that  at  the  most  an  incision  should  be  made  to 
facilitate  the  escape  of  the  fecal  contents.  This  proposal 
did  not  receive  the  sanction  of  the  Societe  de  Chirurgie, 
before  which  it  was  made,  and  the  practice  now  is  to  relieve 
the  constriction  even  when  it  is  not  considered  safe  to  return 
the  bowel.  In  small  hernias  the  sac  must  be  freely  opened 
if  the  strangulation  has  lasted  for  any  length  of  time;  in 
the  larger  ones  the  stricture  may  be  divided,  if  possible, 
outside  the  sac  or  through  a  small  opening  made  in  the  sac 
near  the  ring.  When  the  hernia  seems  to  be  entirely 
omental  the  sac  must  be  divided  and  the  omentum  torn 
through  and  examined,  lest  it  should  contain  a  strangulated 
knuckle  of  intestine. 

The  cutaneous  incision  may  be  straight,  curved,  crucial, 
or  j[-shaped ;  the  tissues  must  be  divided  very  cautiously, 
for  the  coverings  are  thin  and  the  sac  adherent.  The 
stricture  must  be  divided  at  the  upper  portion  and  directly 
upAvard. 

Strangulated  Obturator  Hernia. — A  long  incision  is  made 
parallel  to  the  femoral  vessels  and  about  an  inch  away  from 
them  on  the  inner  side.  The  pectineus  muscle  is  exposed 
and  divided,  as  are  also  any  fibres  of  the  obturator  externus 
whose  division  may  be  necessary  to  give  access  to  the  seat  of 
the  stricture.  The  relations  of  the  artery  and  nerve  to  the 
neck  of  the  sac  must  be  determined,  and  the  division  made 
in  such  a  direction  that  they  will  not  be  injured. 

Radical  Cure  hy  Incision  and  Sutures. — An  incision  is 
begun  a  little  above  the  hernial  orifice  and  carried  down 
along  the  most  prominent  pnrt  of  the  swelling  for  three  or 
four  inches ;  the  layers  are  cautiously  divided,  and  the  sac 
opened  a  little  below  its  neck,  the  hernia  reduced,  the  neck 
of  the  sac  separated  from  the  underlying  parts,  drawn  down- 


HERNIOTOMY,  KELOTOMY.  367 

Wiird,  and  tied  circularly  as  high  as  possible  with  stout 
catgut. 

If  the  attempt  is  made  to  narrow  the  orifice  by  drawing 
its  sides  together,  this  should  be  done  by  threading  a  curved 
-needle  on  each  end  of  a  catgut  or  silk  suture  and  passing 
each  through  one  pillar  of  the  ring  from  within  outward, 
tying,  and  cutting  the  ends  short.  From  tAvo  to  five  such 
sutures  are  I'equired. 

Extirpation  of  the  remainder  of  the  sac  is  sometimes  prac- 
tised, but  is  objectionable.  The  better  plan  is  to  divide  it 
transversely  below  the  ligature,  tie  its  upper  end  circularly, 
wash  it  with  a  strong  carbolic  acid  solution,  close  the  incision 
over  it,  and  drain  it. 

If  the  neck  of  the  sac  is  so  closely  adherent  that  it  cannot 
be  isolated  and  tied,  Schede  recommends  that  a  drainage 
tube  should  be  kept  in  it  until  granulations  have  formed 
which  will  subsequently  close  it. 

If  the  hernia  is  adherent  to  the  sac,  incarcerated,  it  must 
be  separated.  Adherent  omentum  may  be  ligatured  en  masse 
and  cut  off;  adherent  loops  of  intestine  must  be  carefully 
stripped  away  or  the  adherent  portion  of  the  wall  cut  away. 
If  bleeding  from  such  loops  is  anticipated,  the  canal  should 
be  left  open  and  drained. 

The  radical  cure  without  incision  has  been  tried  in  many 
ways,  but  all,  w'ith  perhaps  the  exception  of  Heaton's,  seem 
noAV  to  have  been  quite  generally  abandoned  in  favor  of  the 
cutting  operation.    I  shall  describe  only  Wood  and  Heaton's. 

Radical  Ciire  of  Inguinal  Hernia  (Wood^). — The  prin- 
ciple of  Mr.  Wood's  operation  is  to  draw  the  anterior  and 
posterior  borders  of  the  abdominal  rings  and  the  sides  of 
the  canal  together  above  the  spermatic  cord,  so  as  to  diminish 
the  size  of  the  canal  and  restore  its  valve-like  action.  In 
his  first  twenty  operations  he  used  a  hempen  ligature,  but  he 
afterward  discarded  it  for  a  stout  silvered  copper  wire  about 
two  feet  long.  The  wire  must  not  be  fine,  for  if  it  were  it 
would  cut  through  the  fibrous  aponeuroses  and  defeat  its  own 
object ;  copper  is  better  than  silver  because  it  is  less  likely 
to  kink  and  break,  and  better  than  iron  because  more  flex- 

^  Wood  on  Rupture,  London,  1803. 


368      OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

ible.  The  special  instruments  required  are  a  needle  and  a 
knife.  The  needle  is  stout,  much  curved  in  the  shaft,  less 
so  near  the  point,  and  mounted  in  a  strong  handle  (Fig.  218). 
The  point  is  blunt  and  wedge-shaped,  intended  not  to  cut 
but  to  split  its  way  through  the  tendons.  The  eye  of  the 
needle  should  be  smoothly  counter-sunk  and  slightly  grooved 


Wood's  knife  and  needle  for  radical  cure  of  hernia. 

toward  the  point  so  as  to  lodge  the  wire.  The  knife  is 
small,  the  edge  cutting  only  for  an  inch  near  the  point,  the 
back  stout.  The  end  of  the  handle  should  be  thin,  flat,  and 
rounded,  so  that  it  can  be  used  to  separate  the  fascia  from 
the  skin. 

Anaesthesia  is  essential,  and  must  be  carried  to  complete 
relaxation ;  the  pubis  and  scrotum  must  be  shaved ;  dorsal 
decubitus,  shoulders  well  raised.  The  surgeon  will  find  it 
most  convenient  to  stand  on  the  affected  side,  and  to  use  for 
invagination  the  forefinger  of  his  right  hand  for  the  patient's 
right  side,  and  vice  verm.  The  hernia  is  first  completely 
reduced,  and  if  there  is  any  tendency  to  cough  an  assistant 
must  prevent  its  return  by  making  pressure  over  the  internal 
(deep)  ring  during  the  preliminary  incisions. 

An  incision  from  one  to  two  inches  long  is  made  down- 
ward and  outward  through  the  skin  of  the  scrotum,  over  the 
fundus  of  the  sac  if  the  rupture  is  large,  and  a  little  below 
it  if  small.  If  the  rupture  is  a  bubonocele,  confined  to  the 
inguinal  canal,  the  incision  must  be  made  one  and  a  half 
inches  below  the  s[)ine  <>f  the  pubis.  The  skin  about  the 
incision  is  next  separated  from  the  fascia  over  an  area  of  at 


HERNIOTOMY,  KELOTOMY 


369 


leju'^t   two   iiiclus  ill   diameter;   usually  tliis  can   Itc  aceoiu- 
j)lislie(l  with  the  thin  end  of  the  handle  of  the  knife. 

Next,  the  patient's  tliiij;hs  h;ivin;i:  been  hroufiht  together 
and  Hexed,  the  surn;eon  passes  his  forefinger  into  the  inci- 
sion, the  nail  behind,  and  invaginates  the  fascia  into  the 
canal,  beginning  low  down  so  as  to  get  the  finger  as  much 
as  possible  behind  the  sac,  between  its  fundus  and  the  sper- 
matic cord.      The  linger  is  j)assed  as  far  as  possible  int<j  the 

Fig.  210 


Wood's  radical  oire  of  hornia,  fii-st  puucture.     The  finger  is  beliind  tlie  edge  of  the 
internal  oblique  at  the  internal  ring. 

canal,  and  the  position  of  the  cord  and  Poupart's  ligament 
distinctly  made  out;  then  by  hooking  its  point  forward  the 
lower  border  ojF  the  internal  oblique  muscle  will  be  felt  raised 
upon  it  (Fig.  219),  and  may  be  more  distinctly  recognized 
by  its  greater  thickness  if  the  fingers  of  the  other  hand  are 
placed  over  it  in  the  groin.  By  pressing  the  finger  inward 
the  operator  will  now  feel  at  its  radial  side  the  edge  of  the 


370     OPERATIONS   UPON   ABDOMINAL   WALL,  ETC. 

conjoined  tendon  raised  with  the  muscle  and  placed  in  relief 
on  the  posterior  wall  of  the  canal. 

The  needle,  unarmed  and  well  oiled,  is  then  passed  along 
the  same  side  of  the  finger,  and  pushed  through  the  tendon 
at  its  most  salient  part,  so  as  to  take  up  a  considerable  por- 
tion of  it  (Fig.  219),  and  then  upward  and  inward,  tra- 
versing the  tendon  of  the  external  oblique  (internal  pillar 
of  the  external   ring),  until  its  point  raises  the  skin  of  the 


Fig.  220. 


Eadical  cure  of  hernia.     Making  tlie  third  puncture. 

groin,  which  is  then  drawn  inward  and  a  little  upward  as 
far  as  its  deep  attachments  will  alloAV,  and  the  needle  passed 
through  it. 

One  end  of  the  wire  is  then  passed  through  the  eye  of  the 
needle,  and  the  latter  withdrawn  rapidly,  bringing  the  wire 
after  it.  The  needle  is  then  disengaged  and  passed  along 
the  other  side  of  the  finger  as  high  up  as  the  internal  ring, 


HERNIOTOMY,  KELOTOMY 


371 


;iii<l  tliero  passed  tliroii;:;!!  tlic  anterior  ajxnicin'osis  (cxtci'iial 
pillar),  close  to  Toiipart's  li<^^aiiu'nt  (Fi<,'.  2'20,  B).  The 
skin  is  then  drawn  outAvard,  so  that  the  needle  can  be  passed 
a^^aiii  tliroiiLdi  the  first  ])niieture  in  it,  and,  after  I'eeeiviiii^ 
the  other  end  of  the  Avire,  be  withdrawn  as  l^efore.  The 
two  ends  of  the  wire  now  hang  out  through  the  scrotal  inci- 
sion, and  its  centre  forms  a  loo])  upon  the  groin  (Figs.  220 
and  221);  o7ie  end  has  traversed  the  conjoined  tendon  and 
internal  pillar  of  the  superficial  ring,  the  other  Pouparts 
ligament,  or  the  external  pillar  of  the  same  ring. 

Fig.  221. 


Radical  cure  of  large  hernia.     Withdrawing  tlie  needle. 
A.  The  loop.     B,  C.  The  ends  of  the  wire. 


The  sac  of  the  hernia  and  the  fascia  covering  it  opposite 
the  scrotal  incision  is  then  pinched  up  between  the  finger 
and  thumb,  care  being  taken  not  to  include  the  spermatic 
cord  in  the  fold,  but  to  leave  it  behind  against  the  bone,  and 
the  needle  is  passed  through  it  in  the  direction  of  the  incision, 
picking  up  all  the  tissues  in  front  of  the  cord.  The  needle 
should  enter  and  emerge  through  the  scrotal  incision,  which, 
if  necessary,  must  be  enlarged  for  this  purpose.  One  of  the 
ends  of  the  wire  is  then  hooked  on  to  the  needle  (Fig.  221, 


872      OPERATIONS  UPON   ABDOMINAL  WALL,  ETC. 

B)^  and  (Irawn  with  it  across  the  cord  through  or  behind 
the  sac,  traversing  the  scrotal  fascia.  Either  end  of  the  wire 
may  be  taken,  but  Mr.  Wood  rather  preferred  the  inner  one, 
thai:  which  had  been  passed  through  the  conjoined  tendon, 
as  being  better  placed  to  make  deep  pressure,  arid  more 
easily  withdrawn  at  the  end  of  the  treatment.  The  outer 
one  has  the  advantage  of  giving  an  extra  twist  to  the  sac 
when  drawn  up  and  tightened. 

If  the  rupture  is  small  and  recent,  reaching  only  to  the 
scrotal  incision,  the  wire  may  be  thus  placed  entirely  behind 
the  sac,  between  it  and  the  cord ;  but  if  it  is  larger  and  of 
long  standing,  the  close  adhesions  of  the  cord  will  hardly 
permit  this,  and  the  sac  is  unavoidably  punctured  poste- 
riorly. The  needle  may  also  be  made  to  take  up  a  portion 
of  the  pillars  themselves  close  to  their  insertions,  in  accom- 
plishing Avhich  the  crest  of  the  pubis  can  be  used  as  a  guide 
and  protector  of  the  deeper  parts,  the  needle  being  made 
to  slide  close  to  the  bone.  This  additional  precaution  is 
very  desirable  in  cases  of  large  inguinal  hernia  occurring 
in  females,  in  wdiom  there  is  not  much  fascia  capable  of  in- 
vagination at  this  point. 

In  some  very  small  hernias,  both  in  males  and  females, 
this  last  transfixion  of  the  fascia  or  pillars  may  be  dispensed 
with,  since  anv  great  amount  of  invao-ination  of  the  sac  or 
fascia  is  not  necessary  to  fill  up  a  narrow  hernial  canal  when 
drawn  too^ether  by  the  suture.  In  some  small  hernias  in 
women  a  simple  incision  over  the  superficial  ring,  without 
any  separation  of  fascia,  will  permit  the  accurate  applica- 
tion of  the  sutures,  and  afi'ord  a  free  escape  for  the  dis- 
charges. 

The  next  step  is  to  straighten,  stretch,  and  draw^  down 
both  ends  of  the  wire,  until  the  loop  above  is  close  to  the 
skin,  where  it  is  held  by  an  assistant,  while  the  surgeon 
twists  the  ends  together,  giving  them  three  or  four  turns. 

The  loop  is  then  draw^n  upward,  invaginating  the  sac  and 
scrotal  fascia  inclosed  by  the  twisted  ends  firmly  into  the 
hernial  canal,  and  then,  in  its  turn,  twisted  well  down  into 
the  puncture  in  the  skin  of  the  groin.  Great  care  should 
be  taken  that  the  skin  of  the  scrotum  is  not  draAvn  in  be- 
tween the  pillars  of  the  ring,  and  the  latter  should  also  be 


HERNIOTOMY,  KELOTOMY. 


^)n 


exjimincd  tlirou-jjli  tlic  .scrotal  incision   to  sec  if  it  lias  been 
satisfjictorily  closed. 

The  projecting  ends  of  the  wire  are  cut  off  alxMit  three 
inches  from  the  surface,  bent  into  a  hook,  and  enga<^ed  in 
the  loop,  forming  an  arch  over  the  surface,  in  which  a  pad 
of  lint  is  then  placed  (Fig.  221).  A  broad  spica  bandage 
is  tlieii  placed  over  all. 


Vm.  222. 


Fig   228. 


liadical  cure  of  inguinal  lu-rniu. 
Wires  in  place  and  fastened. 


A,  Wires  as  twisted.     B.  Vertical  section 
showing  disposition  of  the  parts 


Pin  Operation  (Wood). — Tn  congenital  hernia,  and  the 
smaller  kinds  of  rupture  in  children  and  young  boys,  the 
canal  is  usually  narrow,  the  internal  opening  contracted, 
and  the  sides  elongated  so  as  to  retain  much  of  their  valve- 
like action.  Moreover,  the  fascia  and  coverings  are  so  thin 
that  it  is  not  of  much  use  to  transplant  them  into  the  canal. 
In  consideration  of  these  facts,  Mr.  Wood  used  rectangular 
pins  (Fig.  22-1:)  instead  of  the  wire  loop.  The  pins  are 
from  three  to  five  inches  long,  hard  at  the  point,  and  soft 
in  the  shank,  so  as  not  to  break,  and  spear-pqinted  with 
slightly    cutting  edges.      They    are   applied   separately   in 

32 


374      OPERATIONS  UPON   ABDOMINAL   WALL,  ETC. 

opposite  directions,  the  i)oint  of  each  passed  through  the 
loop  at  tlio  angle  of  the  other,  and  the  bent  ends  rotated  in 
opposite  directions  so  as  to  twist  and  compress  the  included 
tissues. 

They  are  applied  in  the  following  manner :  The  child  is 
placed  upon  his  back,  thighs  flexed,  and  hernia  reduced. 
The  scrotum  is  inva^inated  into  the  canal,  and  the  difterent 
parts  recognized  with  the  index  or  little  finger,  which  is 
passed  up  the  canal  until  the  border  of  the  internal  obli(|ue 
can  be  felt  in  front  of  it. 


Fig   224. 


Fig.  225. 


Pins  used  in  the  pin  operation  for 
the  r;i(lical  cure  of  hernia. 

The  skin  is  then  drawn  directly  inward  by  an  assistant, 
and  a  pin  with  its  concavity  directed  downward,  is  passed 
through  it  and  the  intervening  tissues  to  the  inner  side  of 
the  nail  of  the  invaginating  finger  (Fig.  225).  It  is  then 
slid  downward  along  the  side  of  the  finger,  which  is,  at  the 
same  time,  withdrawn,  until  the  point  of  the  pin  can  be  felt 
to  touch  the  pubis.  Skirting  this  bone,  it  is  then  carried 
into  the  scrotum  and  brought  out  through  the  skin  over  the 
fundus  of  the  hernial   sac,  u])on  whicli   the  finger  has  been 


HERNIOTOMY,  KELOTOMV. 


375 


pi'csscd.  Diiriiii^  this  iiianoem  I'c,  the  ))()int  of  tlic  fiii^^cr 
and  llic  j>iii  must  inovo  t<»«^etlic'r,  and  the  rupture  must  he 
kei)t  up  hy  pressing  upon  the  internal  ring  with  tlie  little 
finger  of  the  hand  that  holds  the  pin. 

The  second  pin,  with  its  convexity  directed  f(nward,  is 
then  entered  ])y  the  scrotal  i)uncture  through  which  tlie  first 
})in  emerged,  the  invaginating  finger  placed  below  it,  and 
the  scrotum  again  pushed  up  into  the  canal,  carrying  the 
point  of  the  pin  along  until  it  touches  the  posterior  surface 
of  the  outer  pillar  of  the  superficial  ring.  Through  this  it 
is  then  passed  upward  apd  out- 
ward, so  as  to  raise  the  skin  of  i'^'o-  22G. 
the  groiil  directly  below  the  deep 
(internal)  ring.  The  skin  is  then 
drawn  outward  by  an  assistant, 
and  it  will  be  found  that  by  turn- 
ing the  concavity  of  the  pin  in- 
ward, its  point  can  be  brought 
out  through,  or  very  close  to,  the 
puncture  made  by  the  entry  of 
the  first  pin. 

The  point  of  each  pin  must 
then  be  passed  into  the  loop  of  the 
other,  a  proceeding  which  Avill  be 
much  facilitated  by  first  cutting 
oft*  one  of  them  so  as  to  make  it 
shorter  than  the  other.  After 
they  have  been  thus  fastened 
together  the  point  of  the  other 
pin  is  cut  off",  and  the  bent  ends 
twisted  around  once  more  by 
simply  turning  over  the  end  of 
the  upper  pin  toward  the  thigh. 
The  punctures  and  skin  are  then  The  pius  in  place. 

carefully   protected    by    lint   or 

plaster,  the  bent  end  of  the  pins  tied  together  or  fastened 
down  with  plaster  to  prevent  slipping  (Fig-  -2(3),  and  the 
whole  bound  down  with  a  pad  of  lint  and  a  spica  bandage. 

In  this  operation  the  conjoined  ten(h)n  and  internal  pillar 
are  transfixed  by  the  first  pin,  and  the  outer  pillar  trans- 
fixed and  included  by  the  second  pin.    The  sac  is  transfixed 


376      OPERATIONS  UPON  ABDOMINAL  WALL,  ETC. 

by  both  pins,  which  lie  for  some  distance  in  its  interior. 
These  parts  are  twisted  together  by  turning  one  pin  upon 
the  other,  so  that  the  posterior  wall  is  drawn  forward  and  tlic 
anterior  backAvard,  and  the  canal  is  firmly  closed.  The  cord 
lies  between  and  behind  the  pins  and  is  not  included  by 
them.     The  j^ins  should  be  withdrawn  about  the  tenth  day. 

Radical  Cure  of  Femoral  Hernia  (Wood). — The  instru- 
ments are  the  same  as  those  used  for  the  cure  of  inguinal 
hernia.  Anaesthesia,  dorsal  decubitus,  with  the  shoulders 
raised. 

Fig.  227. 


Eadical  cure  of  femoral  beruia. 

The  rupture  having  been  completely  reduced,  a  vertical 
incision  aljout  an  inch  long  is  made  through  the  skin  over 
the  site  of  the  tumor  (Fig,  227),  and  the  adjoining  fascia 
detached  from  the  skin,  as  before  described,  to  a  sufficient 
extent  to  allow  it  to  be  invaginated  fiiirly  into  the  crural 
opening.  The  forefinger  used  for  invaginating  is  then 
pressed  against  the  inner  side  of  the  femoral  vein,  and  the 


HERNIOTOMY,   KKLUTOMY 


377 


neiMlle  passcfl  lnnkwanl  thmu^li  tlie  «ie,  taking  uj»  the 
j>ul>ic  })urtion  of  fa.scia  lata  covering  the  pectineus  muscle, 
reappearing  in  the  wound,  and  then  passing  forward  and 
upward  through  Poupart's  ligament  close  to  the  nail  of  the 
invaginating  finger  (Fig.  --^5,  A).     The  skin  of  the  groin 


Fig.  228. 


Kadical  cure  of  femoral  hernia. 
A.  First  passage  of  the  needle.     B.  Second  passage  of  the  needle. 

is  then   drawn   outward  by  an  assistant,  the  point  of  the 

needle  passed  through,  the  wire  threaded  upon  it  and  drawn 

throu^li  bv  withdrawing  the  needle. 

I'll 
The  needle  is  then  disencracred  from  the  wire  and  passed 

again  through  the  pubic  portion  of  the  fascia  lata  for  about 

an  inch  (the  distance  varying  with  the  size  of  the  hernial 

opening)  on  the  inner  side  of  the  first  puncture  (Fig.  228,  B), 

and  its  jtoint  passed  in  the  same  manner  through  Poupart's 

ligament  directly  above  and  close  to  the  curved  border  of 

32* 


378      OPERATIONS   UPOX   ABDOMINAL  WALL.  ETC. 

Gimbernats  ligament,  a  portion  of  the  fibres  of  -whicli  may 
be  included.  The  skin  is  then  drawn  inward  until  the  needle 
can  be  pushed  through  the  puncture  previously  made,  and 
which  is  already  occupied  by  the  wire.  The  other  end  of 
the  wire  is  then  engaged  in  the  eye  of  the  needle,  drawn 
back  through  the  wound,  and  disengaged  (Fig.  227).  The 
two  ends  of  the  wire  are  then  twisted  together  in  the  incision 
and  cut  off  about  six  inches  from  the  twist,  and  the  loop 
which  emerges  at  the  upper  puncture  twisted  firmly  down 
into  it,  pressing  down  before  it  the  portion  of  Pouparts 
ligament  included  in  it  opposite  the  crural  opening. 

If  the  hernia  is  small  the  ends  of  the  wire  may  be  hooked 
over  a  pad  of  lint  (Fig.  227,  B),  but  if  it  is  large  and  the 
liojamentous  structures  much  relaxed,  a  cylindrical  box- 
wood  or  glass  compress  (Fig.  227,  A) '  should  be  used. 
Pledgets  of  lint  placed  on  each  side,  and  a  spica  bandage 
over  all  complete  the  dressing. 

The  precautions  chiefly  necessary  during  the  operation 
are :  First,  to  keep  the  finger  carefully  pressed  against  the 
femoral  vein  so  as  to  protect  it  during  the  passage  of  the 
needle;  and  secondly,  to  avoid  pushing  the  needle  too  far 
into  the  abdominal  cavity,  by  which  the  bowel,  the  epi- 
gastric artery,  and  the  spermatic  cord  might  be  endangered. 
The  wire  may  be  kept  in  for  the  same  length  of  time  and 
removed  in  the  same  manner  as  before  described  for  in- 
guinal hernia. 

Radical  Cure  of  Umbilical  Hernia  (Wood). — The  in- 
struments required  are  a  stout  needle  well  curved  near  the 
point,  a  small  spoon-shaped  director  or  scoop  large  enough 
to  fill  up  the  hernial  opening  (Fig.  229),  and  two  pieces  of 
stout  silvered  copper  wire,  each  eight  inches  long. 

The  patient  is  laid  on  the  back,  knees  drawn  up,  and 
shoulders  raised,  and  the  hernia  completely  reduced.  The 
convex  surface  of  the  bowl  of  the  director  is  pressed  into 
the  hernial  opening  so  as  to  carry  the  skin  covering  the  sac 
quite  behind  the  edge  of  the  tendinous  aperture  on  one  side 
of  the  median  line.  The  rounded  end  of  tlie  bowl  must  be 
pressed  steadily  and  firmly  against  the  under  surface  of  the 
tendon,  pushing  the  skin  as  far  as  possible  along  it.  The 
needle,  carrying  one  of  the  wires,  is  then    placed  in  the 


HERNIOTOMY,  KELOTOMY 


379 


hollow  of  the  director,  and  the  i)oiiit  {)iisliL'd  through  tlie 
tendon  from  heliind  tbrAvard,  well  above  the  transverse 
diameter  of  the  opening,  the  skin  being  at  the  same  time 
drawn  upward  by  an  assistant  so  that  it  may  be  pierced  at 


Fia.  229. 


liatlical  cure  of  umbilical  hernia,     a.  Director,     b,  c.  Its  cmLs.     d.  Noodle. 


a  lower  level  than  the  tendon  is  (Fig.  280).  The  wire 
having  been  drawn  through,  the  needle  is  disengaged,  at- 
tached to  the  second  wire,  and  passed  in  the  same  way 
through  the  lower  part  of  the  tendinous  border  on  the  same 
side,  the  skin  this  time  beins;  drawn  downward  so  that  the 
needle  may  pass  through  or  close  to  the  puncture  made 
before  (Fig.  231).  The  second  wire  is  then  drawn  through 
and  the  needle  a^ain  diseno^ao^ed. 


Fig.  230. 


Fig.  231. 


Itadical  cure  of  umbilical  hernia.     Pa&<ins?  the  fii-st  Passing  the  second  wire 

wire 


This  proceeding  must  now  be  repeated  upon  the  opposite 
side  with  the  other  ends  of  the  w^ires ;  the  director  must  be 


380      OPERATIONS   UPON    ABDOMINAL  WALL,  ETC. 


placed  firmly  within  the  hernial  opening,  between  and  be- 
hind the  two  wires  (which  emerge  through  the  skin  at  two 
points  a  short  distance  apart,  in  or  near  the  vertical  dia- 
meter of  the  opening),  so  as  to  push  the  skin  well  over  to 
the  other  side  of  the  median  line  behind  the  edge  of  the 
tendon,  and  make  it  possible  to  enter  the  needle  at  the  same 
punctures  at  which  it  entered  when  carr^nng  the  wires  in 
the  opposite  direction  (Fig.  232).     If  the  opening  is  very 

Fig.  232. 


Passing  the  second  ends  of  the  wires. 


large,  it  will  be  necessary  to  slide  the  point  of  the  needle 
close  under  the  skin  for  a  short  distance  before  piercing  the 
tendon. 

The  two  wires  are  thus  drawn   across  the  opening  and 
through  its  borders  at  equal  distances  above  and  below  its 


Fig.  233. 


Radical  cure  uf  uinMlical  hernia  ;  wires  in  place.     «,  a,  n,  u.  Points  where  the  wires 
pa-ss  through  the  tendon,     b,  h.  Punctures  in  the  skin. 

centre,  passing  out  on  each  side  through  the  same  puncture 
in  the  skin,  and  depressing  the  sac  coverings  within  the 
area  of  the  opening.  When  drawn  tight  they  disappear  into 
the  punctures  first  made  in  the  median  line  for  the  temporary 
purpose  of  their  application   (Fig.   233).     If  the   hernial 


IMPERFORATE    ANUS    OK    RECTUM.  381 

opening  be  very  liirge  a  third  wiiv  ukiv  be  ;i})|)li«tl  in  tlie 
same  manner  across  the  centre  between  the  other  two. 

Tlie  ends  (»f  tlie  wires  on  eacli  side  are  then  twisted  to- 
ijjether  into  tlie  ])unctures  until  the  opening  is  felt  to  be 
closed,  then  cut  off  at  a  suitable  distance,  and  hooked  together 
over  a  roll  of  lint,  tlie  whole  being  retained  by  a  strap  or 
two  of  adhesive  ])laster  :ind  a  circular  bandage. 

Radical  Cure  hy  Injection  (Heaton). — The  injection 
material  is  prepared  as  follows : 

Thayer's  fluid  extract  of  quercus  alba       .         .     .      ^ss. 
Solid  alcoholic       •'       "         u         u  g^.  xiv. 

Triturate  tlioroui^hly  with  2'entle  heat  until  there  is  a  nearly 
perfect  solution  ;  then  add  half  a  grain  of  sulphate  of  mor- 
phia. Ileaton's  needle  has  a  flat  lance-shaped  point  per- 
forated at  several  places,  but  an  ordinary  hypodermic  needle 
may  be  used. 

Operation  (Inguinal  hernia). — The  hernia  is  reduced,  and 
the  point  of  the  index  finger  introduced  well  into  the  ring. 
The  needle  is  then  entered  just  beloAV  the  ring,  and  passed 
upward  between  the  pillars  and  the  sac  about  half  an  inch, 
and  about  half  a  drachm  of  the  solution  injected  into  the  tis- 
sues surrounding  the  neck  of  the  sac  within  the  canal.  It 
must  not  be  thrown  into  the  cavity  of  the  sac. 

The  ii-ritation  of  its  presence  is  expected  to  cause  an 
increase  of  connective  tissue  and  thus  diminish  the  size  of 
the  opening. 

IMPERFORATE  ANUS  OR  RECTUM. 

In  order  to  understand  their  different  congenital  deformi- 
ties, it  is  essential  to  bear  in  mind  the  manner  in  which  the 
rectum  and  anus  are  developed.  The  rectum,  like  the  rest 
of  the  intestine,  is  formed  by  the  third  blastodermic  layer 
of  the  ovule,  and  originally  communicates  with  the  pedicle 
of  the  allantoid  vesicle,  that  which  afterwards  becomes  the 
bladder  and  the  posterior  portion  of  the  urethra.  The 
anus,  on  the  other  hand,  is  formed  by  a  dimple  in  the  outer 
blastodermic  layer,  the  one  which  forms  the  e})idermis.  In 
the  ordinary  course  of  events  the  communication  between 


382      OPERATIONS   UPON   ABDOMINAL   WALL.  ETC. 

the  rectum  and  the  bladder  or  urethra  closes,  and  another 
forms  betAveen  the  rectum  and  anus  by  absorption  of  the 
layer  of  tissue  between  them.  The  malformations  are  the 
result  of  arrest  of  development  of  the  colon,  rectum,  or 
anus,  or  of  the  persistence  of  the  septum,  and  present  several 
varieties. 

The  first,  and  slightest,  is  not  a  true  arrest  of  develop- 
ment, but  a  simple  closure  of  the  orifice  of  the  anus  by  a 
tecrumentarv  layer  or  by  adhesion  of  its  sides,  the  deep  com- 
munication between  it  and  the  rectum  being  complete.  This 
requires  only  separation  of  the  adherent  edges  with  a  director, 
or  division  of  the  layer  with  a  knife. 

2d.  The  rectum  and  anus  may  be  fully  developed,  but 
the  thin  membranous  diaphragm  between  them  may  persist, 
like  the  hymen  in  the  vadna.  The  treatment  of  this  also 
is  simple:   crucial  incision  or  puncture  of  the  membrane. 

3d.  The  anus  may  be  entirely  absent,  while  the  rectum  is 
normally  developed ;  the  distance  between  the  lower  end 
of  the  latter  and  the  surface  being  from  half  an  inch  to  an 
inch. 

-4th.   The  anal  cul-de-sac  being  pr«:»perly  developed,  the 

rectum  or  colon  may  terminate  at  any  distance  above  it.  or 

may  even  not  exist  at  all,  being  represented  by  a  fibrous 

cord  extendincr  from  the  ileo-c^ecal  valve  to  the  anus. 
<_- 

oth.  The  arrest  of  development  may  involve  both  the 
anus  and  the  rectum. 

6th.  The  rectum  may  open  into  the  bladder,  urethra,  or 
vagina. 

It  is  often  exceedinfrlv  difficult  to  determine  the  character 
of  the  malformation  duriuL'  life,  and  vet  it  is  very  important 
that  this  should  be  done,  for  if  the  imperviousness  begins 
at  a  point  too  high  up  to  be  reached  through  the  perineum, 
the  only  possibility  of  relief  is  in  the  establishment  of  an 
artificial  anus  in  the  lumbar  or  inguinal  region.  DepauP 
says  that  when  the  obstruction  begins  at  the  ileo-Ciecal  valve 
the  transverse  distention  of  the  abdomen  is  much  less  than 
in  rectal  obstruction. 

If  the  surgeon  decides  to  go  in  search  of  the  blind  end 
of  the  rectum  and  create  an  anus  in  the  perineum,  he  must 

^  BulL  de  la  Societe  de  Chirurgie,  1877,  p.  536. 


PROLATSK    OF    THE    RECTUM.  383 

make  an  incision  in  tlio  mctlian  line  from  tlie  scintiini  tn  tlie 
tip  of  the  coccyx,  after  having  previously  intrudueed  a 
sound  into  tlie  bladder  if  tlie  patient  is  a  boy,  or  into  the 
va^iina  if  a  giil.  He  then  divides  the  tissues  layer  by  layer 
in  the  line  of  the  incision,  feeling  at  each  step  for  the  dis- 
tended rectum,  whicli  can  sometimes  be  seen  and  felt  to 
bulge  downward  when  tlie  child  strains  or  cries.  Or,  an 
exploratory  })uncture  may  be  made,  and  the  needle  or  trocar 
used  as  a  guide  if  the  bowel  is  reaclie<l  by  it. 

The  search  for  the  bowel  should  be  made  in  the  direction 
of  the  axis  of  the  anal  cul-de-sac,  if  the  latter  is  sufficiently 
developed,  and  advantage  taken  of  the  fact  pointed  out  by 
M.  Forget/  that  a  fibrous  cord,  representing  a  rudimentary 
portion  of  the  rectum,  occupies  more  or  less  of  the  distance 
separating  the  two.  If,  on  the  contrary,  the  anus  is  lack- 
ing, the  search  must  be  made  toward  the  concavity  of  the 
sacrum.  Verneuil  has  proposed  to  excise  the  coccyx,  so 
as  to  diminish  the  danojer  incurred  durinor  the  search,  but 
as  this  is  followed  by  prolapse  of  the  rectum  it  should  be 
practised  only  when  a  simple  incision  has  proved  insufficient. 

When  the  end  of  the  bowel  is  reached  it  must  be  seized 
with  pronged  forceps,  or  two  stout  ligatures  must  be  passed 
through  it,  and  it  must  be  partly  separated  from  the  adjoin- 
ing tissues,  drawn  down,  opened,  and  made  fast  to  the 
integument  or  the  margin  of  the  anus.  The  anterior  and 
posterior  portions  of  the  cutaneous  incision  must  finally  be 
closed  by  sutures. 

AVhen  the  rectum  opens  into  the  vagina  it  may  be  reached 
through  a  longitudinal  or  crucial  incision  in  the  perineum, 
separated  from  the  vaginal  wall  with  a  knife  or  curved  scis- 
sors, and  drawn  down  and  fastened  as  before.  The  former 
opening  will  then  close  spontaneously. 


PROLAPSE  OF  THE  RECTUM. 

The  mucous  meml)rane  of  the  rectum  is  very  loosely 
attached  to  the  muscular  coat,  and  when  the  sjdiincter  is 
relaxed  or   disabled  prolapse  may  occur  to  a  degree   that 

1  Bull,  de  la  Socidte  de  Chirurgie,  18G3  and  1877. 


384   OPERATIONS  UPON  ABDOMINAL  WALL,  ETC. 


requires  operative  interference.  ^Jliis  interference  may  in- 
volve the  mucous  membrane  alone,  or  it  may  also  include 
the  anus.  In  the  former  case  the  indication  is  to  promote 
adhesions  between  the  mucous  and  muscular  coats,  or  to 
remove  portions  that  may  be  in  excess  ;  in  the  latter  to 
narrow  the  anal  orifice.  The  former  is  accomplished  by 
making  deep  longitudinal  incisions  througli  the  mucous  mem- 
brane, or  by  pinching  up  folds  at  three  or  four  different 
points  and  tying  a  strong  ligature  about  each.  The  inci- 
sions are  likely  to  give  rise  to  severe  hemorrhage,  and  con- 
se(j[uently  the  method  has  fallen  into  disuse ;  the  actual 
cautery,  however,  applied  at  points  or  in  lines,  has  been 
used  as  a  substitute. 

There  are  two  methods  of  narrowing  the  anal  orifice. 
Dupuytren  pinched  up  with  forceps  several  of  the  radiating 
folds  of  integument  and  cut  them  off  with  curved  scissors, 
trusting  to  cicatricial  retraction  for  tlie  narrowing  he  de- 
sired. 

Robert  made  two  incisions,  extending  from  the  extremities 
of  the  transverse  diameter  of  the  anus  to  the  tip  of  the 
coccyx,  removed  the  skin,  subcutaneous  tissue,  and  portion 
of  the  sphincter  contained  within  the  V  thus  marked  out, 
and  brought  the  sides  of  the  gap  together  with  sutures. 

RECTOTOMY. 

Cases  of  stricture  of  the  rectum  not  suitable  for  dilatation 
or  division  by  some  of  the  specially  contrived  rectotoraes, 
must  be  treated  by  section  posteriorly  in  the  median  line. 
The  sphincter  is  first  forcibly  dilated,  and  then  a  blunt  di- 
rector forced  through  the  wall  of  the  rectum  in  the  median 
line  below  the  stricture,  and  brouo;lit  back  into  the  rectum 
in  the  same  line  above  it.  Then  by  hooking  a  loop  of  stout 
wire  over  the  point  of  the  director  I  have  always  found  it 
possible  to  draw  the  stricture  as  far  down  toward  the  anus 
that  it  could  safely  be  divided  layer  by  layer  with  the 
knife,  and  any  bleeding  points  secured  with  ligatures.  Or 
the  wire  of  an  ecraseur  may  be  passed  in  the  same  man- 
ner. The  preliminary  dilatation  of  the  spliincter  sliould  be 
very  thorough  ;  and  in  some  cases  it  is  advisable  to  divide 
the  sphincter  posteriorly  with  the  knife. 


EXCISION   OF   ANUS   AND   PART  OF   RECTUM.      385 


EXCISION  OF  THE  ANUS  AND  I'AKT  OF  THE  RKCTUM. 

This  operation  may  be  rendered  necessary  by  malignant 
disease,  and  may  be  performed  Avitli  the  knife,  ligature,  or 
ecraseur.  It  must  be  remembered  that  the  peritoneum  de- 
scends upon  tlie  anterior  surface  of  the  rectum  to  within 
about  an  inch  of  the  prostate,  but  not  c(uite  so  far  upon  the 
sides  or  behind  :  its  average  distance  from  the  anus  is  from 
two  to  two  and  one-half  inclies  in  front,  and  fiv^e  inches  be- 
hind ;  consequently,  if  the  upper  limit  of  the  tumor  on  the 
posterior  side  cannot  be  reached  by  the  end  of  the  finger 

introduced    tlirou^h    the    anus,  its    removal  should   not  be 

•  •  •  1 

attempted.     The  nature  and  extent  of  its  connections  with 

the  important  organs  on  the  anterior  surface  must  also,  of 

course,  be  carefully  determined. 

A.  Removal  by  the  Knife. — Two  curved  incisions,  meet- 
ing in  front  and  behind  in  the  median  line,  are  made  through 
the  skin,  one  on  each  side  of  the  anus,  and  at  a  distance 
of  about  one  inch  from  it.  They  are  carried  down  to  the 
rectum,  remaining,  of  course,  external  to  the  neoplasm  if  it 
has  broken  through  the  rectal  wall,  and  the  rectum  is  then 
dissected  upward  as  far  as  necessary,  using  the  fingers  in- 
stead of  the  knife  for  this  purpose  whenever  possible.  A 
sound  should  be  introduced  into  the  bladder  as  a  guide  if 
the  patient  is  a  man,  and  a  finger  into  the  vagina  if  the 
patient  is  a  woman.  When  the  upper  limit  of  the  tumor  is 
reached,  the  rectum  is  drawn  well  down,  its  posterior  wall 
divided  longitudinally,  and  the  diseased  portion  removed. 

If  the  disease  extends  upward  more  than  one  and  a  half 
inches,  it  is  advisable  to  make  an  additional  incision  back- 
ward to  the  tip  of  the  coccyx,  and  perhaps  even  to  extend  it 
along  the  side  of  this  bone. 

Velpeau  took  the  precaution  to  pass  a  number  of  threads 
through  the  intestine  above  the  proposed  line  of  excision, 
bringing  them  out  through  the  skin  beyond  the  external 
limits  of  the  disease.  After  the  removal  of  the  tumor,  he 
had  only  to  tighten  and  tie  these  threads  to  bring  the  edges 
of  the  incisions  through  the  intestine  and  the  skin  together. 


B86      OPERATION'S  UPOX   ABDOMINAL  WALL.  ETC. 

Richard  Volkmann^  has  modified  tliis  operation  somewhat 
and  claims  that  by  thorough  drainage  and  the  strictest  atten- 
tion to  disinfection  of  the  woun<l  during  and  after  the  ope- 
ration, excision  of  the  rectum  can  be  carried  to  a  very  con- 
siderable height,  and  even  the  peritoneal  cavity  opened, 
without  danger  to  the  patient.  He  empties  the  bowel 
thorouo:hlv,  makes  a  circular  incision  about  the  anus,  a 
straicrht  one  in  the  median  line  back  from  the  circular  one 
to  the  coccyx,  and,  if  necessaiy,  another  in  the  median  line 
of  the  perineum  ;  the  bowel  itself  must  not  be  cut  into.  He 
then  draws  the  rectum  down,  dissects  it  out  circularly  to  the 
necessary  height,  passes  ligatures  through  the  healthy  por- 
tion after  Yelpeau's  plan,  and  cuts  off  the  lower  portion 
containing  the  tumor.  Bleeding  points  are  temporarily 
secured  by  self-retaining  forceps,  and  afterward  with  catgut. 

K  the  peritoneal  cavity  is  opened,  a  sponge  soaked  in  a 
salicylic  acid  or  thymol  solution  is  kept  pressed  against  the 
opening,  until  the  excision  is  completed  ;  then  if  the  opening 
is  small  its  edges  are  drawn  out  with  artery  forceps,  and  a 
lio^ature  thrown  around  it  as  if  it  was  a  vessel :  if  it  is  larore. 
it  is  closed  with  catgut  sutui-es. 

The  upper  end  of  the  gut  is  then  drawn  down,  and  fast- 
ened to  the  skin  very  accurately  with  alternate  deep  and 
superficial  sutures,  two  or  three  drainage  tubes  are  inserted, 
cut  off  close  to  the  surface,  and  stitched  fast. 

During  the  operation,  the  bleeding  surface  is  constantly 
protected  against  infection  by  irrigation  with  an  antiseptic 
solution,  and  for  the  first  thi-ee  or  four  days  constant  anti- 
septic irrigation  is  kept  up  through  a  tube  passed  well  into 
the  wound  near  one  of  the  drainage  tubes ;  daily  antiseptic 
injections  are  afterward  made  through  the  drainage  tubes 
until  the  wound  has  healed. 

Yolkmann  claims  that  these  precautions  strictly  carried 
out  insure  the  patient  against  what  has  heretofore  been  the 
chief  danger  of  the  operation,  that  of  exciting  diffuse  pelvic 
cellular  inflammation,  which  spreads  rapi(lly  upward  behind 
the  peritoneum,  and  causes  death  by  septic  peritonitis. 
Although  the  bleeding  during  the  operation  is  very  severe, 
he  has  never  known  it  to  have  fatal  consequences. 

^  Ueber  den  Mastdarmkrebs  imd  die  Exstirpatio  recti  in  Klinischer 
Vortroge,  No.  181  (Chirurgie,  Xo.  42),  p.  1113,  13ih  March,  1878. 


EXCISION   OF   ANUS  AND   PART   OF   KECTUM.      387 

lie  thinks,  also,  that  cancer  is  much  less  likely  to  return 
locally  after  excision  of  the  anus  than  it  is  when  the  sphinc- 
ters are  preserved,  an<l,  therefore,  he  prefers  total  excision 
of  the  anus  and  of  the  rectum  to  the  upper  limit  of  the  dis- 
ease, even  when  the  anus  itself  is  not  involved. 

I  must  add  that  the  best  result  in  my  experience  or  ob- 
servation, freedom  from  recurrence  that  has  now  lasted  for 
seven  years,  followed  removal  of  the  tumor  alone,  a  mass 
two  and  a  half  inches  in  diameter  (m  tlie  posterior  wall  of  the 
rectum,  and  beginning  one  and  a  half  inches  above  the  anus. 
After  dilatation  of  the  s'phincter  I  made  an  incision  through 
it  in  the  posterior  median  line  up  to  the  tumor,  and  cut  the 
latter  out  with  scissors,  keeping  one-third  inch  from  it  all 
around.  The  bleeding  was  free,  but  the  vessels  were  readily 
secured.  The  sides  of  the  gap  were  drawn  together  in  the 
form  of  a  +,the  longitudinal  inci.sion  closed  with  sutures, 
and  a  drainage  tube  placed  behind  the  bowel  and  brought 
out  at  the  posterior  angle  of  the  incision. 

B.  Ronoval  hy  Ligature. — Recamier  removed  the  lower 
end  of  the  rectum  and  anus  by  including  its  entire  circum- 

FiG.  234. 


Extirpation  of  anus.     Recaniier'ts  methoil. 


ference  within  a  number  of  ligatures,  which   were   tightly 
tied,  and  then  left  to  cut  their  way  out.     He  used  two  stout 


388   OPERATIOXS  UPON"  ABDOMINAL  WALL,  ETC. 

cords  of  diiferent  colors,  passing  them  by  means  of  a  hollow 
curved  needle,  containing  a  central  movable  stylet,  furnished 
Avith  a  large  eye  in  its  anterior  end.  and  then  tying  the  ends, 
Avhich  were  of  the  same  color,  together  in  pairs  (Fig.  234). 
The  method  is  difficult  of  execution  and  painful,  and  has 
been  advantageously  modified  by  Maisonneuve,  as  follows : 
The  surgeon  marks  with  ink  upon  the  skin  the  outer  limits 
of  the  cancer,  and  di^-ides  the  integument  along  the  mark 
with  the  knife.  He  then  places  stout  hempen  threads  as 
before,  the  loop  lying  inside  the  bowel,  the  end  coming  out 
through  the  incision  in  the  skin.  These  threads  may  be 
placed  by  means  of  a  needle  like  Kecamier's,  or  by  a  curved 
needle  with  an  eye  large  enough  to  carry  two  threads  at  a 
time  passed  from  within  outward,  or  by  means  of  a  long 
slightly  curved  needle  mounted  on  a  handle,  and  having  an 
eye  at  its  point.  This  needle  is  armed  with  a  rather  fine 
thread,  and  passed  through  the  incision  into  the  bowel  above 
the  tumor,  where  the  thread  is  then  caught  with  forceps  or 
tenaculum,  and  the  needle  withdrawn  (Fig.  235.  A). 


Fig.  235. 


Fig.  236. 


Method  of  .<nrrounding  the  lower  bowel 
with  ligatures. 


Extirpation  of  rectum.     MaiBonnenre. 


Along,  stout,  hempen  ligature  is  then  passed  through  the 
loop  of  the  fine  ligatui'e  left  within  the  intestine  (Fig.  235, 
B),  and  di-awn  by  means  of  it  through  the  puncture  made 


HEMORRHOIDS.  380 

by  the  needles  so  tliat  its  centre  comes  out  tlirongh  tlie  inci- 
sion, and  its  two  ends  through  the  anus.  Each  end  is  then 
drawn  through  successive  punctures  in  the  same  manner 
(Fig.  235,  C),  and  after  the  bowel  has  been  thus  entirely 
surrounded,  the  external  loops  (Fig.  23(3,  a,  «,  a)  are  cut. 

The  two  en<ls  of  each  short  ligature,  into  which  the  long 
one  has  been  thus  cut  up,  are  attached  to  a  constrictor,  and 
gradually  tightened  until  the  included  tissues  are  divided. 

■  C.  Removal  by  the  Ecraseur. — Alphonse  Guerin^  has 
operated  successfully  by* the  following  method.  He  first 
incised  the  skin  around  the  anus  with  the  knife,  and  then 
divided  the  rectum  longitudinally  with  the  ecraseur  from 
above  the  tumor  to  the  tegumentary  incision.  Then  by 
means  of  a  curved  needle  he  passed  the  chain  of  the  ecra- 
seur horizontally  about  a  portion  of  the  intestine  above  the 
tumor  and  divided  it,  repeating  this  operation  until  the 
entire  circumference  of  the  rectum  had  been  cut  through. 
If  the  tumor  does  not  involve  the  entire  circumference,  he 
circumscribes  it  by  two  vertical  incisions,  and  divides  only 
that  portion  of  the  circumference  which  lies  between  their 
upper  ends. 

HEMORRHOIDS. 

Concerning  the  treatment  of  hemorrhoids  by  ligation  there 
are  a  few  points  wdiich  deserve  mention.  The  sphincter 
should  be  temporarily  paralyzed  by  forcible  dilatation. 
Every  pile  that  is  more  than  half  an  inch  in  diameter  must 
be  transfixed  by  a  needle  carrying  a  double  ligature,  and 
then  strangulated  by  tying  it  at  its  base ;  the  smaller  piles 
do  not  need  to  be  transfixed,  it  is  sufficient  to  throw  a  single 
ligature  about  each.  When  the  tegumentary  margin  is 
included  in  the  ligature  a  groove  should  be  snipped  in  it 
with  scissors.  The  ends  of  the  ligatures  should  not  be  cut 
off  as  soon  as  they  are  tied,  but  after  three  or  four  have 
been  placed  at  opposite  points  of  the  circumference,  it  will 
be  found  easy  to  get  an  excellent  view  of  the  interior  by 
drawing  them  outward  and  apart.     The  temporary  paral- 

1  Cbirurgie  Operatoire,  4th  edition,  1869,  p.  582. 
3:3* 


390      OPERATIONS   OX   G  EX  I  TO  -  U  R  I  X  A  R  Y  ORGANS. 

ysis  of  the  sphincter  not  only  facilitates  the  examination 
and  operation,  but  it  spares  the  patient  pain  during  conva- 
lescence. 


CHAPTEE   VII. 

OPERATIONS  UPON  THE  GENITO-UEINARY  ORGANS  OF  THE 

MALE. 

CASTRATION. 

After  the  parts  have  been  well  shaved,  the  surgeon 
makes  the  skin  covering  the  testicle  tense,  and  makes  a 
straight  incision  aloncr  the  entire  lenofth  of  the  anterior 
portion  of  the  scrotum,  beginning  at  a  point  just  below  the 
external  abdominal  ring.  The  testicle  is  then  forced  out 
through  the  incision  and  freed  from  its  coverincrs  more  bv 
tearing  than  by  the  use  of  the  knife.  The  cord  is  isolated 
for  the  necessary  distance,  and  divided  at  the  lowest  point 
allowed  by  the  extension  of  the  disease  which  has  rendered 
the  operation  necessary. 

Various  modifications  of  the  incision  have  been  employed  : 
Amussat  and  Roux  made  it  upon  the  posterior  surface  of 
the  scrotum.  Jobert  gave  it  the  shape  of  a  semicircle  with 
its  convexity  downward  and  outward.  Lafarge  removed  an 
elliptical  portion  of  skin  circumscribed  by  two  curved  in- 
cisions, and  Rima  removed  the  lower  portion  of  the  scrotum, 
and  the  testicle  with  it,  by  two  transverse  incisions  made  by 
transfixing  behind  the  cord  and  cutting  downward  and  back- 
ward for  one  of  them,  and  directly  forward  for  the  other. 
If  the  lavers  of  the  scrotum  are  adherent  to  the  testicle,  and 
if  the  latter  has  become  exceptionally  large,  the  dissection 
must  be  carefully  conducted  so  as  to  avoid  injury  to  the 
erectile  tissue  of  the  penis  and  to  the  other  testicle. 

The  cord  mav  be  licratured  m  mas^p.  or.  better,  in  two 
parts  after  transfixion  with  a  double  ligature,  and  then 
divided  half  an  inch  below  the  lifjature.  the  ends  of  which 
are  cut  loner  and  brouf]jht  out  at  the  dependent  ande.     This 


HYDROCELE.  391 

is  the  iiu'tliod  generally  julopted  ;  its  advantages  are  the 
ease  with  Avhieh  it  is  j)erf()rnie(l,  its  simplicity  and  security, 
and  the  facility  with  which  the  stump  can  ])e  reached  if 
hemorrhage  occurs.  The  disadvantages  are  the  possibility 
of  causing  tetanus  by  including  the  nerves  in  the  ligature, 
and  the  length  of  time,  a  week  or  more,  which  is  required 
for  its  separation.  The  alternative  method  is  to  transfix 
the  cord  with  a  stout  ligature  and  divide  it  with  a  succession 
of  short  cuts,  tying  each  vessel  separately.  The  ecraseur 
and  galvano-cautery  have  proved  inefficient  to  prevent  hem- 
orrhage. Malgaigne  simply  divided  the  cord  and  prevented 
hemorrhage  by  making  pressure  with  a  truss  over  the  in- 
guinal canal.  It  sometimes  happens  that  consecutive  hem- 
orrhage occurs  from  the  cord,  and  is  sufficient  to  endanger 
the  life  of  the  patient ;  in  such  a  case  the  wound  must  be 
reo})ened,  and  the  bleeding  vessel  sought  for  within  the 
inguinal  canal,  into  which  the  cord  has  a  strong  tendency 
to  retract ;  if  necessary,  the  anterior  wall  of  the  canal  must 
be  divided. 

Before  closing  the  wound  great  care  must  be  taken  to 
secure  all  bleeding  points  in  the  scrotum  by  twisting  or 
tying,  for  after  no  other  operation  is  troublesome  consecutive 
hemorrhage  so  common.  The  raw"  surface  must  be  care- 
fully examined  and  all  clots  picked  off,  in  order  that  the 
vessels  w^hich  they  occlude  may  be  more  securely  closed. 
The  edges  of  the  wound  should  be  united  with  sutures,  and 
a  drain  j^laced  in  the  dependent  angle. 


HYDROCELE. 

The  operations  for  the  relief  of  hydrocele  are  'palliative 
or  radical.  The  object  of  the  former  is  simply  to  remove 
the  li(|uid  from  the  sac ;  that  of  the  latter  to  prevent  its  re- 
accumulation  by  excising  the  sac,  or  by  obliterating  its 
cavity  by  exciting  adhesive  inflammation  of  its  walls.  In- 
jection of  the  tincture  of  iodine  is  the  means  most  commonly 
employed  for  the  latter  purpose.  The  position  of  the  tes- 
ticle within  the  sac  should  always  be  ascertained,  in  ordep 
that  it  may  not  be  injured  by  the  trocar.  This  is  best  ac- 
complished in  most  cases  by  examining  the  sac  by  trans- 


392      OPERATIONS   ON   GE  NITO  -  U  R  IN  A  RY   ORGANS. 

mitted  light,  the  testicle  appearing  as  an  opaque  spot  in  the 
general  translucency ;  its  usual  position  is  at  the  lower  pos- 
terior portion  of  the  sac. 

Puncture  of  the  Sac. — The  tumor  is  grasped  at  its  upper 
portion  in  such  a  manner  as  thoroughly  to  stretch  the  skin 
covering  it,  and  a  well-oiled  trocar  is  plunged  into  the  centre 
of  its  anterior  surface,  supposing  the  testicle  to  occupy  its 
usual  position  below  and  behind.  The  depth  to  which  the 
trocar  enters  is  regulated  by  the  finger  placed  along  its  side, 
and  the  surgeon  satisfies  himself  that  the  point  is  well  within 
the  sac  by  moving  it  freely  in  all  directions.  The  canula 
should  fit  the  trocar  snugly  in  order  that  its  anterior  end 
may  not  push  the  tissues  before  it  instead  of  penetrating 
them.  If  the  intention  is  only  to  remove  the  liquid,  the 
canula  is  withdrawn  as  soon  as  the  flow  has  ceased,  and  the 
puncture  closed  with  adhesive  plaster  or  collodion :  but  if  a 
radical  cure  is  to  be  attempted,  the  tincture  of  iodine  must 
first  be  thrown  in.  The  French  surgeons  use  the  tincture 
diluted  with  two  or  three  parts  of  water,  and  prevent  pre- 
cipitation by  adding  iodide  of  potassium  to  the  mixture. 
They  throw  a  considerable  quantity  into  the  sac,  retain  it 
there  for  three,  four,  or  five  minutes,  and  then  withdraw  it. 
Van  Buren  and  Keyes^  recommend  the  "pure  tincture 
thrown  in  gradually,  retained  several  minutes,  and  worked 
around  in  such  a  way  that  every  portion  of  the  inner  wall 
of  the  sac  may  come  into  contact  with  it ;"  the  quantity  of 
the  tincture  used  should  be  equal  to  half  the  amount  of 
liquid  drawn  ofi".  Large  hydroceles  must  first  be  reduced  in 
size  by  one  or  two  tappings.  The  injection  of  a  few  grains 
of  carbolic  acid  dissolved  in  glycerine  has  given  good  results. 

Care  must  be  taken  that  the  injection  is  not  thrown  into 
the  subcutaneous  connective  tissue,  an  accident  that  is  very 
likely  to  be  followed  by  sloughing  of  the  scrotum ;  the  surest 
way  of  avoiding  this  accident  is  to  throw  in  the  injection 
before  the  liquid  has  entirely  ceased  to  flow  out.  If  the 
accident  does  occur,  free  incisions  must  be  made  at  once  into 
the  scrotum  at  the  seat  of  the  infiltration. 

1  Genito-Urinary  Diseases  with  Syphilis,  New  York,  1874,  p.  404. 


VARICOCELE.  898 

Radical  Cure  hij  Iiicmon  (Volkiiiunn). — The  sac  is  freely 
laid  open  by  a  longitudinal  anterior  incision,  and  the  incised 
edges  of  the  skin  and  tunica  vaginalis  stitched  together  all 
around.  Excessive  reaction  is  prevented  ])y  antise])tic  dress- 
iuir.  If  the  wall  of  the  sac  is  much  thickened,  it  must  be 
dissected  off  and  excised. 


VARICOCELE. 

The  treatment  of  varicocele  may  be  palliative  or  radical. 
By  the  former,  support  is  given  to  the  testicle  and  the  over- 
distended  veins ;  by  the  latter,  it  is  sought  to  obliterate  the 
lumen  of  the  veins  at  one  or  more  points.  There  are  several 
risks  involved  in  the  radical  treatment,  which,  when  taken 
in  connection  Avitli  the  usual  harmlessness  of  the  affection 
and  the  efficacy  of  palliative  measures,  should  make  the 
surgeon  slow  to  employ  it.  The  risks  are  :  Possible  phle- 
bitis, which  may  lead  to  py?emia;  possible  atrophy  of  the 
testicle,  in  consequence  of  the  obliteration  of  all  the  veins 
or  the  inclusion  of  the  artery  in  the  ligature ;  and  finally, 
the  likelihood  of  a  return  of  the  affection  if  all  the  veins 
are  not  obliterated.  The  palliative  treatment  consists  in 
wearing  a  suspensory  bandage,  or  in  excising  a  large  portion 
of  the  scrotum,  with  the  expectation  that  what  is  left  will 
act  as  a  natural  suspensory. 

Excision  of  the  Scrotum. — A  long  clamp  is  required, 
between  the  blades  of  which  a  larore  fold  of  the  scrotum  is 
pinched  up  parallel  to  and  including  the  raphe.  This  fold 
is  then  cut  off  about  one-eighth  of  an  inch  from  the  outer 
side  of  the  blades,  and  numerous  interrupted  sutures  applied 
before  the  clamp  is  removed.  If  bleeding  is  feared,  these 
sutures  should  be  cut  about  a  foot  long,  and  not  tied  until 
after  the  clamp  has  been  taken  off,  and  all  bleeding  points 
secured. 

The  radical  treatment  consists  in  obliterating  the  lumen 
of  the  veins  by  dividing  them  with  the  knife  or  the  cautery, 
excising  a  portion  of  their  length,  compressing  and  strangu- 
lating them  by  means  of  ligatures  or  clamps,  or  simply 
exposing  them  to  the  air. 


394      OPERATIONS   ON   GEN  ITO- U  RIN  AR  Y  ORGANS. 

Division  and  excision  are  unsafe,  even  when  the  veins 
are  compressed  above  and  below  by  harelip  pins  and  twisted 

sutures. 


Compression  hy  Pins. — The  bundle  of  veins  is  pinched 
up  and  carefully  separated  from  the  cord  and  artery,  which 
lie  close  together  behind  the  veins  and  can  be  readily  dis- 
tinguished by  the  firm  whipcord-like  sensation  given  by  the 
former  when  it  is  rolled  between  the  thumb  and  finfjers. 

n  •  • 

The  pin  is  then  passed  through  transversely  between  the 
veins  and  the  cord,  and  an  elastic  or  a  silk  ligature  thrown 
around  its  ends.  It  is  well  to  place  two  pins  about  an  inch 
apart. 

Compression  hy  Wires  (Vidal's  method). — Vidal  passed 
a  stout  wire  between  the  veins  and  the  cord,  as  before  de- 
scribed, and  a  thinner  wire  through  the  same  holes  in  the 
skin,  but  in  front  of  the  bundle  of  veins  (Fig.  237).  The 
two  wires  were  then  twisted  together  (Fig.  239),  so  as  to 


Fig.  237. 


Fig.  238. 


VidaPs  uperatiou  fur  varicocele. 

compress  the  veins  included  between  them,  and  turned  a  few 
times  so  as  to  roll  up  the  bundle  of  veins  around  them  (Fig. 
238).  Ulceration  occurs  at  the  point  of  compression,  and 
the  inflammation  spreads  to  the  adjoining  parts,  matting  the 
veins  together,  and  occluding  them  in  several  places.  Du- 
brueil  has  modified  this  by  making  the  thin  wire  form  part 
of  a  galvanic  circuit  and  raising  it  to  red  heat. 


VARICOCELE. 


805 


SubriiUineous  Ligature. — A  iit'edle  carrying  a  catgut  or 
antiseptic  silk  ligature  is  pa.sse<l  through  between  the  veins 
and  the  cord,  reentered  at  the  point  of  emergence,  passed 
around  the  other  side  of  the  veins  close  under  the  skin,  and 

Fig.  239. 

brought  out  and  tightly  tied  at  the  first  point  of  entry.  If 
this  is  very  exactly  done,  so  as  not  to  include  the  deeper 
part  of  the  skin  at  either  puncture  in  the  loop,  and  is  treated 
antiseptically.  it  will  usually  heal  without  suppuration.  Its 
execution  is  "facilitated  by  making  the  punctures  with  a  knife. 

Ricord's  Method. —  Ricord  passed  a  needle  carrying  a 
thread  between  the  veins  and  cord,  made  the  thread  ffist  to 
the  loop  of  a  stout  ligature  and  drew  it  through,  leaving 
the  loop  projecting  through  one  puncture,  the  two  ends 
throuf^h   the    other.      The    needle    and    thread    were    then 


Ricords  method  ol  tying  the  veins  iu  vuricucele 

passed  again  in  the  opposite  direction,  through  the  same 
punctures,  but  in  front  of  the  veins,  and  a  second  ligature 
drawn  through.  The  ends  of  each  ligature  were  then 
passed  through  the  loop  of  the  other,  drawn  tight  so  as 
thoroughly  to  compress  the  veins,  and  then  attached  to  the 
apparatus    shown    in   Fig.    240,   and    tightened   every  day 


396      OPERATIONS   ON  GENITO- URIN  A  R  Y  ORGANS. 

until  the  bundle  was  cut  through.  Or  the  ends  may  he 
tied  together  over  a  roll  of  bandage  placed  in  front  between 
the  two  punctures,  and  tightened  daily. 

Rigaud's  3Iethod  hy  Exposure. — Prof.  Rigaud,  of  Stras- 
burg  and  Nancy,  has  had  great  success  in  obtaining  oblitera- 
tion by  simple  exposure  of  the  veins  to  the  air.  He  pinches 
up  a  transverse  fold  of  skin,  transfixes  it  and  cuts  out,  dis- 
sects out  the  bundle  of  veins  carefully,  passes  a  strip  of 
well-greased  linen  under  it,  and  binds  a  pad  of  charpie  over 
it.  The  veins  shrink  as  soon  as  they  are  exposed,  the  blood 
coagulates  in  them  immediately,  and  in  a  few  days  spon- 
taneous division  occurs,  or  they  are  reduced  to  a  fibrous 
cord.  At  the  time  his  paper  was  written^  he  had  operated 
upon  nineteen  varicoceles  and  one  hundred  and  forty  cases 
of  varicose  veins  of  the  leg.  In  three  cases  the  veins  were 
accidentally  opened,  and  those  three  cases  died  of  pyemia; 
all  the  others  were  entirely  successful. 


AMPUTATION  OF  THE  PENIS. 

If  the  amputation  is  to  be  made  through  the  pendulous 
portion  hemorrhage  may  be  prevented  by  tying  a  ligature 
tightly  about  the  root  of  the  organ.  It  is  generally  stated 
that  the  erectile  portions  retract  more  extensively  than  the 
skin,  and  must  therefore  be  cut  longer,  but  this  appears  to 
be  incorrect,  the  skin  is  more  retractile  than  the  corpora 
cavernosa,  and  must  be  drawn  well  back  toward  the  pubis 
before  it  is  divided.  The  division  may  be  made  with  the 
knife,  ecraseur,  or  cautery;  there  is  no  objection  to  the  use 
of  the  former  on  the  score  of  hemorrhage,  but  it  is  more 
often  followed  by  pyaemia  than  either  of  the  others. 

In  order  to  prevent  cicatricial  contraction  of  the  urethral 
orifice  the  inferior  wall  of  that  canal  should  be  divided, 
together  with  the  skin,  for  about  half  an  inch,  and  the 
edores  of  the  mucous  membrane  made  fast  to  those  of  the 
skin  with  fine  sutures.  Some  surgeons  consider  this  longi- 
tudinal incision  unnecessary,  and  are  satisfied  to  draw  out 


1  Bulletin  de  la  Societe  de  Chirurgie,  1875,  p.  464. 


OPERATIONS,  FOR    PHIMOSIS.  397 

the  mucous  membrane  slightly  and  stitch  it  fast  to  the  skin. 
If  the  longitudinal  incision  is  to  be  made,  it  is  desirable 
to  cut  the  urethra,  if  possible,  half  an  inch  lunger  than  the 
corpora  cavernosa.  Singular  as  it  may  seem,  it  is  some- 
times difficult  to  find  the  orifice  of  the  urethra  on  the  surfiice 
of  section. 

If  the  amputation  is  to  be  made  close  to  the  symphysis, 
two  accidents  must  be  guarded  against ;  they  are :  retrac- 
tion of  the  penis,  and  infiltration  of  urine  into  the  scrotum. 
To  prevent  the  former,  a  stout  ligature  should  be  passed 
through  the  sheath  of  the  penis  a  little  above  the  point 
selected  for  amputation:  to  prevent  the  latter,  and  also  to 
give  the  patient  better  command  of  the  direction  of  his 
stream  of  urine,  the  scrotum  should  be  divided  in  the  me- 
dian line  and  the  anterior  and  posterior  edges  of  each  half 
brought  together,  so  as  to  form  two  distinct  scrotums  with 
the  urethra  exposed  between  them. 

OPERATIONS  FOR  PHIMOSIS. 

Dorsal  Incision. — A  director  is  passed  through  the  pre- 
putial orifice  along  the  dorsum  of  the  ghms  to  the  corona, 
a  curved,  sharp-pointed  bistoury  guided  along  it,  the  skin 
transfixed  at  the  point  of  the  director  and  divided  straight 
down  to  the  preputial  orifice.  Xothing  more  is  absolutely 
required,  for  the  wound  left  to  itself  will  heal  promptly; 
but  it  is  well  to  round  off  the  corners  and  to  unite  the  edges 
of  the  mucous  membrane  and  skin  by  fine  sutures.  This  is 
a  very  satisfactory  operation  when  the  prepuce  is  not  re- 
dundant, but  if  there  is  much  excess  of  tissue  the  foreskin 
will  present  an  awkward,  lop-eared  appearance  for  many 
yeai-s,  and  in  such  cases,  therefore,  circumcision  is  to  be 
preferred. 

This  operation  is  often  required  in  cases  of  sub-preputial 
chancroid,  and  then  it  becomes  a  matter  of  considerable 
importance  to  prevent  inoculation  of  the  wound  by  the 
chancroidal  virus.  A  method  introduced  by  Dr.  J.  H. 
Lowman  into  the  venereal  wards  of  Charity  Hospital,  Xew 
York,  has  proved  very  efficient  in  this  respect.  A  solution 
of  nitrate  of  silver,  forty  grains  to  the  ounce,  is  injected 
under  the  prepuce,  and  followed  by  the  injection  of  a  satu- 

?A 


398      OPERATIONS   ON   GENITO-URTN AR Y  ORGANS, 

rated  solution  of  common  salt,  to  remove  the  excess  of  the 
caustic.  The  sore  having  been  thus  rendered  temporarily 
innocuous  by  the  coagulation  of  its  secretions,  the  incision 
is  made  and  the  sore  cauterized  with  nitric  acid. 

Circumcision. — A  number  of  instruments  have  been  in- 
vented, and  a  great  variety  of  methods  proposed,  which  do 
not  need  to  be  repeated  here,  for  the  object  they  had  in 
view,  that  of  insurino;  division  of  the  skin  and  mucous  mem- 
brane  of  the  prepuce  at  the  same  level,  is  not  a  matter  of 
much  importance,  since  any  excess  of  the  latter  can  be 
readily  removed  afterward.  There  is,  however,  one  modi- 
fication introduced  by  Dr.  Keyes^  which  is  of  great  im- 
portance, for  it  insures  the  removal  of  the  constriction  and 
protects  the  wound  from  being  harmed  by  erections  while 
healins:.  This  modification  consists  in  an  additional  lonori- 
tudinal  division  of  the  skin  for  about  half  an  inch  along  the 
dorsum  of  the  penis,  and  sometimes,  also,  on  the  opposite 
side  along  the  course  of  the  urethra,  after  the  end  of  the 
prepuce  has  been  cut  off  (Fig.  242,  AC).  The  corners 
left  by  these  incisions  are  rounded  ofi",  and  the  effect  is  to 
increase  the  circumference  bv  twice  the  length  of  the  inci- 
sion.  As  the  stricture  is  sometimes  due  to  insufficient 
breadth  of  the  skin  covering  the  glans,  the  value  of  this 
simple  modification  is  evident. 

Operation. — A  probe  is  first  introduced  and  swept  over 
the  surface  of  the  glans  to  break  up  any  adhesions  that 
may  exist,  and  the  edge  of  the  preputial  orifice  is  then 
caught  at  opposite  points  with  the  thumb  and  forefinger  of 
each  hand  and  drawn  forward,  care  being  taken  to  make 
the  tension  upon  the  less  elastic  mucous  membrane,  and  not 
only  upon  the  skin.  While  the  prepuce  is  thus  drawn  for- 
ward, an  assistant  clasps  a  pair  of  long  narrow-bladed 
forceps  vertically  upon  it  just  in  front  of  the  apex  of  the 
glans,  directing  the  blades  forward  as  well  as  downward 
(the  penis  being  horizontal)  parallel  to  the  general  direc- 
tion of  the  corona,  and  the  glans  should  then  be  moved 
freely  behind  them  to  make  sure  that  it  is  not  caught  be- 

^  Van  Buren  and  Keyes,  Gcnito-Urinarv  Diseases,  with  Syphilis, 
New  York.  1874,  p.  ll/ 


OPERATIONS    FOK    PHIMOSIS. 


399 


;weeii  the  l.hi.U's.     'rhc  portion  of  pivpiu-e  in  tnmt  of  the 
orcoDS  is  tlieii  cut  awiiy  with  scissors  or  ii  knite  (big.  141), 


twee 

force) 

and  the  forceps  taken  otl, 


Fig.  I'll. 


Circumcision      Fii-st  incision. 

It  will  then  be  seen  that  the  glans  is  still  covered  by  a 
more  or  less  tightly  fitting  sheath  of  mucous  membrane, 
while   the   looser  and  more   elastic  skin 
retracts  to  or  beyond  the  corona,  leaving 
a  belt  of  raw  surface  below  (Fig.  242). 

The  mucous  membrane  is  next  divided 
with  scissors  along  the  dorsum  back  to 
the  corona  (Fig.  242,  BB\  and  the  skin 
divided  in  the  same  direction  along  the 
dorsum  for  a  distance  of  half  an  inch  from 
its  cut  edge  (Fig.  242,  AC),  and  also  on 
the  under  side  along  the  urethra,  if  con- 
sidered necessary.  The  corners  of  these 
incisions  are  rounded  off,  and  the  edges 
of  the  mucous  membrane  and  skin  fasten- 
ed together  with  numerous  fine  sutures, 
the  first  being  placed  exactly  in  the  me- 


Circumcision.  Riiw 
surface  left  by  rctrac- 
tion  after  first  incision. 


400      OPERATIONS   ON   G  ENITO-U  RIN  A  R  Y   ORGANS. 

dian  line  in  front,  the  second  at  the  frenum.  If  fine  silk 
is  used,  and  the  sutures  placed  close  to  the  edge,  they  may 
be  left  to  cut  their  way  out  and  come  away  in  the  dressings. 
It  is  always  difficult  to  get  accurate  adjustment  of  the 
edges  at  the  ends  of  the  longitudinal  incisions  on  the  dor- 
sum, and  usually  a  small  trianguhir  gap  is  left  to  fill  by 
granulation.  Dr.  D.  B.  Delavan^  proposes  to  meet  this 
objection  by  leaving  a  triangular  piece  projecting  in  the 
'  centre  of  the  dorsal  portion  of  the  cutaneous  incision.  Fig. 
243  shows  the  line  of  incision,  Fig.  244  the  resulting  tri- 
angles of  skin  and  mucous  membrane  ;  the  apex  of  the  latter, 
H,  which  at  first  is  drawn  upward  by  its  close  connection 


Fig.  243. 


Fig.  244. 


Circumcision.     Delavan.     First  incision. 


Circumcision.    Delavan.     Fitting  in  tlie 
triangle. 


with  the  apex  of  the  skin  triangle,  A^  so  that  its  mucous 
surface  is  outward,  is  represented  in  the  figure  as  it  appears 
after  having  been  freed  by  dissection,  if  necessary,  and  turned 
down,  leavino;  its  raw  surface  out.  The  mucous  membrane 
is  then  slit  ujd  to  the  corona  at  2),  as  usual,  after  cutting 
away  its  triangle,  and  the  point  A  is  stitched  fast  to  i).  B  to 
E^  0  to  F^  and  the  remainder  of  the  edge  as  usual. 

The  only  objection  to  be  made  to  this  device  is  that  it 
sacrifices  the  liberatino;  lonfjitudinal  incision  of  the  skin,  and 
Dr.  Keyes^  has  met  this  by  taking  the  triangular  flap  from 
the  mucous  membrane  instead  of  from  the  skin.  He  cuts 
off"  the  prepuce  by  a  straight  incision,  and  divides  the  skin 


^  Oral  communication,  1876. 


2  Oral  communication,  1876. 


PARAPHIMOSIS. 


401 


aloiii^  the  (lorsiiin  as  ))ef<)ro ;   and  tlien,   instcatl  of  splitting 
tlic  iiiiicoiis  iiR'inljraiio  in  tht'  same  manner  (Fig.  -42,  />/>), 
he  makes  a  Y-shaped  incision  (Fig.  245,  BDC)^  and  removes 
tlie  anterior  strip  of  mucous  membrane 
by  continuing  the  incision  from  C  and 
I)  around  to  the  frenum.     The  point 
DBC'is  then  reflected,  fitted  into  the 
triangular  gaj)  GUF  It'fi  by  the  lon- 
gitudinal incision  in  the  skin  and  the 
rounding  of  its  corners,  and  the  edges 
are  united  by  sutures,  as.  before. 

If  broad  adhesions  exist  between 
the  glans  and  prepuce,  and  it  is  feared 
that  the  raw  surfaces  left  bv  their 
division  will  reunite,  all  the  mucous 
membrane  may  be  removed,  except  a 
rinji;  about  one-eiixhth  of  an  inch  wide 
adjoining  the  corona  ;  the  skin  is  then  loosened  by  dissection 
from  the  underlyin2:  tissues,  drawn  forward,  and  united  to 
the  narrow  ring  of  mucous  membrane.  The  raw  surface  on 
the  glans,  having  nothing  to  adhere  to,  cicatrizes  naturally. 


Circumcisiou.     Keyes. 


PARAPHIMOSIS. 


A  description  of  the  methods  of  reduction  by  taxis  or  by 
compression  of  the  engorged  prepuce  and  glans  does  not  lie 
within  the  proposed  scope  of  this  Avork,  and  the  operation 
of  division  of  the  constricting  band  hardly  needs  to  be 
described,  for  it  consists  simply  in  dividing  the  band  from 
without  inward  at  one  or  more  points,  until  the  constriction 
is  sufficiently  relieved  to  allow  the  prepuce  to  be  drawn  for- 
ward. It  is  well  to  make  the  first  incision  in  the  median 
dorsal  line  so  as  to  profit  by  it  afterward,  if  an  operation 
for  phimosis  is  considered  necessary.  If  inflammatory  ad- 
hesions have  formed  along  the  line  of  the  constriction,  forcible 
attempts  to  reduce  the  paraphimosis  should  n(jt  be  made, 
but,  after  division  of  the  band,  the  parts  should  simply  be 
dressed  with  cold  and  soothincr  lotions. 

34* 


402      OPERATIONS   ON   GEN  ITO-U  RIN  ARY  ORGANS, 


DIVISION  OF  THE  FRENUM. 

Verneuil^  employs  the  following  method  :  He  makes  the 
frenum  tense,  transfixes  it  close  to  its  attachment  to  the  glans 
with  a  narrow  bistoury  or  tenotome  held  with  its  side  parallel 
to  the  surface  of  the  penis,  and  cuts  out  backward,  making 
a  triangular  flap  nearly  half  an  inch  long,  with  its  apex 
directed  backward.  The  liberated  glans  is  drawn  forward, 
the  flap  disappears,  and  the  edges  of  the  wound,  whicli 
assumes  the  shape  of  a  lozenge,  are  united  by  sutures. 


EPISPADIAS. 

The  deformity  known  as  epispadias  is  characterized  by 
fissure  of  the  roof  of  the  urethra.  In  its  complete  form  it 
is  associated  with  separation  of  the  symphysis  pubis,  and 
often  with  exstrophy  of  the  bladder,  in  which  case  its  treat- 
ment is  subordinate  to  that  of  the  more  important  defect 
[q,  v.).  In  its  slightest  degree  it  is  confined  to  a  fissure 
occupying  the  dorsal  portion  of  the  glans  penis,  and  extend- 
ing from  the  meatus  to  the  corona  (epispadias  balanique). 
The  existence  of  this  form  has  been  denied,  but  VerneuiP 
reports  two  cases,  in  neither  of  which  did  the  malformation 
cause  any  disturbance  of  function.  In  the  more  important 
varieties  the  urethra  lies  above  the  corpora  cavernosa  instead 
of  below  them,  and  is  open  on  the  roof  from  its  anterior  ex- 
tremity nearly  to  the  bladder ;  the  glans  is  fairly  developed, 
and  may  be  grooved  more  or  less  deeply  along  its  dorsum, 
wdiile  the  rest  of  the  corpus  spongiosum  is  represented  by  a 
thin  layer  of  erectile  tissue  under  the  urethra.  There  is 
sometimes  partial  or  complete  incontinence  of  urine,  and  the 
operative  indication  is  to  supply  a  channel  through  which 
the  urine  can  be  conducted  without  dribbling  to  a  urinal. 

NeJatons  Method. — The  prepuce  is  drawn  downward  and 
forward  by  means  of  a  ligature  passed  through  it,  and  held 
in  this  position  during  the  operation.     An  incision  is  then 

1  Chirurgie  K^paratrice,  1877,  p.  730.  '^  Loc.  cit.,  p.  718. 


EPISPADIAS 


403 


iiijidc  aloiiL'  viu-h  si<lc  of  tlic  iirotliral  flutter  at  the  jniK'tion 
of'tlic  ^kiii  and  iimcou.s  iiicmbranc,  bcgiiiiiiiig  at  tlio  piepuce 
and  ending  at  tlie  abdominal  ^vall.  The  external  lip  of 
each  incision  is  dissected  up  for  about  one-sixth  of  an  inch, 
forming;  a  flap  on  each  side  continuous  -svith  the  skin  ;  the 
inner  lij)  of  each  incision  is  also  slightly  loosened.  The  flaps 
must  be  made  as  thick  as  possible. 

A  third  Haj)  is  then  marked  out  upon  the  abdominal  Avail, 
immediately  above  the  urethral  orifice  leading  to  the  bladder, 
by  two  vertical  incisions  united  at  their  upper  ends  by  a 
transverse  one ;  it  shoul(J  be  as  broad  as,  and  a  little  longer 

Fig.  246. 


Epispaclisis.  Nelaton"s  operation.  A.  Abdominal  flap.  B.  Urethnil  infundibiiluui. 
C,  C.  Lateral  inci.-*ion.s  at  junction  of  skin  and  mucous  membrane.  F,  F.  Scrotal  inci- 
sions circumscribing  G  the  scrotal  flap. 

than,  the  penis,  dissected  from  above  downward  to  its  base, 
which  corresponds  to  the  interpubic  ligament,  and  then  re- 
versed, its  cutaneous  surface  inward,  and  its  sides  made  fast 
by  sutures  to  the  inner  lips  of  the  incision  on  the  penis,  care 
being  taken  to  make  the  contact  as  broad  as  possible. 
Demar<juay^  and  Dolbeau'  preferred  to  make  the  flap  by 
prolonging  the  first  two  incisions  up  the  abdomen,  thinking 

^  Maladies  Chirurj^icules  du  Penis,  1877,  \>.  623. 

2  De  PEpispadias,  Paris,  1861.     Planche  IV.,  Fig.  I. 


40  J:      OPERATIONS    OX   GE  N  ITO- U  R  T  X  A  K  Y   ORGAXS. 

that  the  continuity  of  the  incisions  upon  the  abdomen  and 
penis  would  increase  the  chances  of  success  (Fig  246,  C  C). 

In  order  to  give  the  abdominal  flap  greater  thickness,  and 
prevent  its  retraction  during  the  process  of  cicatrization, 
Xelaton  reinforced  it  by  another  taken  fi'om  the  scrotum. 
This  scrotal  flap  is  limited  by  concentric  curved  incisions 
(Fig.  246,  FF)^  the  upper  one  circumscribing  the  under 
half  of  the  root  of  the  penis  in  the  peno-scrotal  angle,  the 
other  at  a  distance  below  the  first  equal  to  the  length  of  the 
penis,  and  is  left  adherent  at  both  ends.  After  the  flap  has 
been  dissected  up,  the  penis  is  passed  under  it,  bringing  the 
raw  surface  of  the  reversed  abdominal  flap  into  contact  with 
that  of  the  scrotal  flap,  and  the  great  circumference  of  the 
latter  is  fastened  by  three  sutures  to  the  outer  lips  of  the 
two  incisions  made  alono^  the  sides  of  the  urethral  orutter. 

The  canal  thus  formed  is  very  large,  and  both  Xelaton 
and  Dolbeau  found  it  necessary  to  diminish  its  size  by  ap- 
plying the  actual  cautery  to  its  interior.  The  operation 
devised  by  Thiersch  is  generally  deemed  superior. 

Tldcrsclis  Method} — This  operation  recjuires  several 
months  for  its  completion,  since  it  is  composed  of  four  dis- 
tinct operations  performed  at  different  times.     In  order  to 

Fig.  247. 


Episr>adiao.  Thiersch's  operation.  1.  The  glans  seen  from  above.  A.  A.  The  inci- 
sion on  each  side  of  the  gntter  C.  B,  B  The  freshened  surface.  2.  Transverse  section 
of  glans  showing  the  incisions  3.  The  freshened  surfaces  brought  together  and  closing 
in  the  urethra  U. 


prevent  the  urine  from  coming  into  contact  with  the  raw 
surfaces  of  the  flaps  Thiersch  makes  an  opening  into  the 

^  Archiv  fiir  Heilkiinde,  18G9,  pp.  20-36,  and  Langenbeck's  Archiv, 
vol.  XV.  Part  II.  p.  379. 


EPISPADIAS. 


405 


urethra  tlirou<j;li  tlio  perineum  and  maintains  it  during  tlie 
entire  period  of  treatment. 

First  Step  (Fig.  247). — Creation  of  the  meatus  and  the 
])(n*tion  of  the  eanal  occupying  tlie  glans.  The  surgeon 
makes  a  deep  incision  along  each  side  of  the  urethral  groove 
in  the  glans,  pares  the  surface  of  the  outer  lip  of  each  inci- 
sion, brings  the  freshened  surfaces  into  contact,  and  fixes 
tlicm  Avith  two  or  three  points  of  twisted  suture. 

Second  Stej)  (Figs.  248,  249). — Creation  of  the  urethra 
along  the  body  of  the  penis.     The  surgeon  makes  an  inci- 


Fia.  248. 


Fig.  240. 


Epispadias.  Tliiersch.  Se- 
cond step  Incisions  limiting 
the  two  lateral  Haps. 


Ei)ispadias.     Thiersch.     Transverse  section  of  penis, 
showing  flaps. 


sion  through  the  skin  and  subcutaneous  tissue  at  tke  edge  of 
the  urethral  smtter  on  the  rijjht  side,  makes  a  short  trans- 
verse  cut  outward  from  each  end,  and  dissects  up  the  rec- 
tangular flap  thus  marked  out.  On  the  left  side  he  makes 
a  longitudinal  incision  one  centimetre  external  to  the  edge 
of  the  gutter,  and  a  transverse  incision  from  each  end. 
This  flap  is  dissected  up,  making  it  as  thick  as  possible,  and 
turned  over  so  as  to  form  a  roof  for  the  urethral  gutter,  its 
cutaneous  surfece  directed  downward,  its  raw  surface  upward. 
Several  ligatures  are  passed  through  it  near  its  free  border 


406      OPERATIONS   ON  GENITO-URIN  A  R  Y  ORGANS. 

and  then  through  the  base  of  the  right-hand  flap,  and  the 
hitter  draAvn  across  the  former  so  that  their  raw  surfaces  are 
brought  into  contact  throughout.  The  free  edge  of  the  right 
flap  is  then  fastened  to  the  skin  forming  the  outer  edge  of 
the  incision  on  the  left  side. 

Third  Step. — To  close  the  gap  remaining  between  these 
two  new  portions  of  the  urethra.  A  transverse  incision  is 
made  in  the  prepuce,  the  glans  passed  through  it,  the  bor- 
ders of  the  gap  pared  and  fastened  to  the  edges  of  the  inci- 
sion in  the  prepuce. 

Fourth  Step. — To  close  the  posterior  portion  of  the  canal 
or  infundibulum.  The  method  employed  is  similar  to  that 
used  in  the  second  step  of  the  operation,  the  flaps  being 
taken  from  the  groins.  The  left  flap  has  the  form  of  an 
isosceles  triangle,  and  its  base  occupies  the  left  half  of  the 
upper  semi-circumference  of  the  opening ;  it  is  turned  over 
so  that  its  cutaneous  surface  is  directed  downward,  and  its 
free  border  is  united  to  the  freshened  posterior  edge  of  the 
roof  of  the  new  urethra.  The  other  flap  is  quadrilateral, 
its  base  corresponds  to  the  right  inguinal  ring,  and  it  is 
drawn  over  the  first  one  so  that  their  raw  surfaces  are 
brouo;ht  into  coiitact  and  fastened  tou'ether  with  sutures. 

Finally,  the  fistula  established  in  the  j^erineum  is  closed. 


HYPOSPADIAS. 

The  deformity  known  as  hypospadias  is  characterized  by 
a  congenital  abnormal  opening  of  the  urethra  upon  the 
under  surface  of  the  penis.  Sometimes  the  urethra  ends 
at  the  abnormal  opening,  sometimes  it  is  continued  more  or 
less  imperfectly  beyond  it,  either  in  the  form  of  a  tube, 
which  is  usually  imperforate  at  one  or  two  points,  or  in  that 
of  a  gutter.  The  varieties  of  hypospadias  are  usually 
classified  in  three  groups,  the  balanitic,  penile,  and  scrotal, 
according  as  the  abnormal  opening  is  found  at  a  point  in  the 
urethra  corresponding  to  the  glans,  the  pendulous  portion 
of  the  penis,  or  the  scrotum.  The  balanitic  is  the  most 
frequent  and  least  important,  and  the  penile  is  less  frequent 
and  less  important  than  the  scrotal.  The  defect  never  ex- 
tends further  back  than  the  bulb  of  the  urethra,  and  conse- 


HYPOSPADIAS.  407 

([iiently  never  tMiises  iiicoiitiMencc  of"  urine.  In  the  scrotal 
and  in  some  of  the  penile  varieties  the  anterior  portion  ot" 
the  urethra  forms  a  tense  fibrous  cord  binding  down  the 
irhms,  curving  tlie  ])ody  of  the  penis  upward,  an<l  prevent- 
ing its  erecticm. 

In  tlie  bahmitie  variety,  when  the  anterior  portion  of  the 
urethra  exists  in  tlie  form  of  a  gutter,  no  treatment  is  re- 
([uired  unless  the  opening  is  too  small.  The  slight  defi- 
ciency in  length  involves  no  loss  of  function,  and  attempts 
to  reconstitute  the  defective  portion  of  the  canal  by  some 
plastic  operation  usually  fail.  In  fact,  if  the  canal  exists 
between  the  meatus  and  the  abnormal  opening,  it  is  better 
to  slit  it  up  than  to  try  to  close  the  latter. 

The  scrotal  variety  is  considered  irremediable,  and  has 
never  been  the  subject  of  surgical  interference.  In  it  the 
scrotum  is  bifid,  the  penis  usually  very  small,  and  the 
urethral  orifice  at  the  bottom  of  an  infundibulum  resemblinjx 
a  vulva.  Individuals  thus  deformed  have  often  been  mis- 
taken for  hermaphrodites  and  sometimes  for  females. 

In  the  penile  variety,  when  the  anterior  portion  of  the 
urethra  is  normal,  the  opening  may  be  closed  by  freshening 
the  surface  about  its  edge  and  covering  it  with  a  flap  taken 
from  the  adjoining  skin.  When  the  anterior  portion  exists 
only  in  the  form  of  a  more  or  less  shallow  groove,  it  may  be 
transformed  into  a  complete  canal  by  one  of  the  methods  of 
urethroplasty  hereinafter  described.  The  two  other  modes 
of  operating,  urethroraphy  and  perforation,  have  now  been 
discarded  :  in  the  former  the  edges  of  the  groove  were  pared 
and  brouorht  too;ether  with  sutures,  in  the  latter  a  trocar  was 
passed  aloncj  through  the  tissues  of  the  under  side  of  the 
penis  from  the  extremity  of  the  glans  to  the  abnormal  open- 
ing of  the  urethra,  and  the  route  thus  created  kept  open  by 
the  frequent  passage  of  sounds. 

If  the  penis  is  incurvated  it  must  be  sfraightened  as  a 
preliminary  to  any  operation.  To  accomplish  this  it  is  not 
suflicient  to  divide  only  the  fibrous  band  on  its  under  sur- 
face, for  the  retraction  is  partly  maintained  by  the  shortness 
of  the  inferior  portion  of  the  sheaths  of  the  corpora  caver- 
nosa and  the  septum  between  them.  If  the  skin  on  the 
under  surface  is  flexible  enough  to  allow  the  penis  to  be 
straightened  after  the   internal  bands    have  been   divided. 


408      OPERATIONS   ON  GENITO-UR  IN  A  R  Y   ORGANS. 

this  division  may  be  made  siibcutaneously,  following  the 
example  of  Bouisson,  by  introducing  a  tenotome  and  press- 
ino-  its  edo^e  air-ainst  the  sheath  of  the  eorijora  cavernr>sa  and 
the  septum  while  the  glans  is  <lrawn  steadily  away  from  the 
scrotum.  Ordinarily,  however,  this  is  not  possible,  and  one 
or  two  transverse  incisions  one  centimetre  long  must  be 
made  through  the  skin  and  deeper  parts.  By  the  straight- 
ening of  the  penis  these  transverse  incisions  are  transformed 
into  longitudinal  ones,  and  their  sides  are  then  drawn  to- 
gether by  sutures.  Several  months  must  then  be  allowed 
to  elapse  before  the  subsequent  plastic  operation  is  under- 
taken, in  order  that  the  cicatrix  may  become  perfectly  soft 

and  attain  its  full  vitality. 

%/ 

In  the  earlier  operations  of  urethroplasty/  the  floor  of  the 
urethra  was  formed  by  a  long  narrow  vertical  flap  taken 
from  the  scrotum,  its  base  adjoining  the  orifice  of  the  urethra, 
and  its  borders  f\\stened  to  the  edo-es  of  two  lono-itudinal 
incisions  on  the  under  side  of  the  penis.  In  short,  the 
method  resembled  that  already  described  as  employed  by 
Nelaton  for  the  relief  of  epispadias,  even  to  the  reinforce- 
ment of  the  flap  by  a  transverse  one  taken  from  the  skin 
above  the  root  of  the  penis.  The  results  of  these  attempts 
were  so  unsatisfactory  that  when  Nelaton  was  consulted,  in 
1872,  concerning  a  patient  aflected  with  hypospadias,  he 
advised  that  nothing  should  be  done,  saying  that  he  had 
made  many  canals  through  which  the  urine  was  carried  to 
the  end  of  the  penis,  but  they  interfered  with  erection,  and 
did  not  facilitate  fecundation.^  The  surgeon  who  received 
this  advice,  Theophile  Anger,  thereupon  devised  another 
method,  ignorant  that  a  similar  one  had  been  employed 
shortly  before  by  Thiersch  in  epispadias  and  by  Scymanow- 
ski  for  urethral  fistula,  and,  having  put  it  into  execution, 
obtained  an  excellent  result. 

Theophile  Anger  s  3Iethod. — In  this  case  the  uretliral 
opening  was  at  the  peno-scrotal  angle,  the  anterior  portion 
of  the  canal  was  entirely  lacking,  and  the  penis  was  so  curved 
that  the  extremity  of  the  glans  was  not  more  than  half  an 

^  Theophile  Anger  in  Bull,  de  la  Soc.  de  Chirurgie,  seance  du  21 
Janvier,  1874. 


HYPOSPADIAS 


409 


inch  from  the  openin^r.  The  penis  was  first  strai^nrhtenefl 
by  two  short  transverse  incisions  carried  to  such  a  depth 
that  the  corpora  cavernosa  were  exposed  at  the  bottom  of 
the  wound ;  the  bleedinor  was  sliorht,  and  the  wound  liealed 
promptly.  The  phistic  operation  was  performed  nearly 
four  months  afterward,  and  was  only  partially  successful, 
the  posterior  portion  of  the  flap  disappearing  by  absorption. 
A  second  operation,  six  months  later,  was  entirely  success- 
ful, and  the  condition  of  the  parts,  when  the  patient  was 
shown  to  the  Societe  de  Chiruririe  five  months  afterward, 
was  entirely  satisfactory,  the  tissues  were  supple,  there  was 
no  stricture  in  the  canal,  and  erection  was  perfect,  except 
for  a  very  slight  incurvation  downward. 

Fig.  250. 


Hypospadias.     Theophile  Anger's  method. 


The  first  plastic  operation  was  as  follows  :  An  incision, 
extending  from  the  glans  to  the  scrotum,  was  made  through 
the  skin  on  the  left  side  parallel  to  the  median  line  and  one 
and  a  half  centimetres  from  it,  and  from  each  extremity  of 
this  an  obli<|ue  incision  was  carried  to  the  median  line,  the 
posterior  one  ending  on  the  scrotum  just  behind  the  urethral 

35 


410      OPERATIONS   ON   G  E  N I  TO-U  R  I N  A  R  Y   ORGANS. 

opening  (Fig.  250).  The  cutaneous  flap  circumscribed  by 
these  three  incisions  was  dissected  up  so  that  it  could  be 
turned  back  with  its  epidermic  surface  directed  inward,  and 
thus  constitute  the  floor  of  the  new  canal.  A  second  longi- 
tudinal incision  was  then  made  a  little  to  the  right  of  the 
median  line,  parallel  to  and  as  long  as  the  first,  a  transverse 
incision  one  and  a  half  to  two  centimetres  long  carried  out- 
ward from  each  end  of  it,  and  the  flap  thus  circumscribed 
dissected  up. 

A  sound  was  then  introduced  into  the  urethra,  the  first 
flap  di'awn  back  over  it,  and  six  sutures  placed  close  to  its 
free  longitudinal  border :  the  two  ends  of  each  suture  were 
then  attached  to  a  needle  and  carried  through  the  base  of 
the  second  flap  from  within  outward,  as  shown  in  the  figure, 
drawn  tight,  and  fixed  by  pinching  a  tube  of  lead  upon 
them.  Finally,  the  second  flap  was  di'awn  over  the  first, 
and  its  edge  made  fast  to  the  (»uter  lip  of  the  first  incision, 
thus  covering  in  all  the  raw  surface. 

Anofer  tied  in  the  catheter  and  left  it  for  several  davs, 
but  admits  that  this  was  a  mistake.  When  he  repeated  the 
operation  he  left  the  catheter  in  for  only  twenty-four  hours, 
and  then  reintroduced  it  only  when  the  urine  had  to  be 
drawn  off". 

JJuplay's  Method. — The  operation  has  three  steps  or 
stages.  In  the  first,  the  penis  is  straightened  and  a  meatus 
made :  in  the  second,  the  portion  of  the  urethra  which  is 
lacking  is  restored ;  and  in  the  third,  this  new  portion  is 
united  to  that  which  previously  existed. 

Fir-<t  Stej). — The  penis  is  straightened  by  transverse  or 
subcutaneous  incision  as  before  described,  and  the  meatus 
made  by  paring  a  sti-ip  of  the  surface  of  the  glans  on  each 
side  of  the  groove  representing  the  urethra,  and  bringing 
them  together  with  one  or  two  points  of  twisted  suture  over 
a  piece  of  gum  catheter  placed  in  the  groove.  If  necessaiy, 
the  groove  may  be  deej^ened  by  one  or  two  longitudinal  inci- 
sions on  its  floor  (roof  of  the  urethra). 

Second  Step. — Two  longitudinal  incisions,  extending  fi'om 
the  glans  nearly  to  the  abnormal  urethral  opening,  are  made, 
one  on  each  side  of  the  median  line,  at  a  distance  from  each 
other  equal  to  the  circumference  to  be  given  to  the  new 
urethni :  and  from  each  end  of  these  a  short  transverse  in- 


URETHRAL    FISTULJ? 


411 


cisioii  is  made  toward,  but  not  ({uitc  to,  the  median  line 
(Fig.  251,  ^1).  The  rectanguLar  flaps  tliiis  circiimseribed 
are  dissected  up  toward  the  median  line,  turned  back  over 
a  gum  eatlieter,  and  their  free  borders  fastened  together 
with  sutures  (Fig.  -ol,  B  and  C).     The  outer  li})s  of  the 


Fio.  2-,i. 


Hypospadias.     Diiplay's  inethud. 

two  incisions  are  then  loosened  sufficiently  by  dissection  to 
allow  them  to  be  drawn  over  the  others  and  fastened  to- 
gether in  the  median  line  with  interrupted  or  twisted  sutures. 
Care  must  be  taken  to  attach  the  anterior  ends  of  all  four 
flaps  to  the  pared  surface  of  the  glans,  so  that  the  new 
urethra  may  be  continuous  with  the  piece  previously  made. 
Third  Step. — To  close  the  gap  between  the  termination 
of  the  old  and  the  beginning  of  the  new  portions  of  the 
urethra,  Duplay  freshened  the  edges  and  brought  them  to- 
gether with  double  rows  of  sutures. 


URETHRAL   FISTULA. 

Urethral  fistuh^,  as  a  rule,  are  more  difficult  to  close  the 
further  they  are  from  the  bladder.  Those  occupying  the 
perineum  and  scrotum  are  long,  pass  through  thick  tissues, 
and  will  usually  heal  spontaneously  if  the  full  calibre  of  the 
urethra  in  front  of   them  is  maintained.     Occasionally  it 


412      OPERATIONS   ON   GENITO-U  RIN  A  RY  ORGANS. 

becomes    necessary  to  freshen    their   sides  with   the  knife, 
caustics,  or  cautery. 

FistukTS  occupying  the  pendulous  portion  of  the  penis 
have  but  little  tendency  to  close  spontaneously,  unless  they 
are  recent  and  small ;  the  distance  between  the  mucous  and 
cutaneous  surfaces  is  so  short  that  the  walls  of  the  fistula 
cicatrize  promptly  without  uniting,  and  that  renders  a  spon- 
taneous cure  practically  impossible.  Operations  undertaken 
for  the  purpose  of  closing  them,  exclusive  of  simple  cauteriz- 
ation, are  divided  into  two  classes,  urethrorapliy  and  urethro- 
plasty. In  the  former,  the  sides  of  the  fistula  are  pared 
and  brought  together  in  the  median  line ;  in  the  latter,  the 
loss  of  substance  is  made  good  by  the  transfer  of  cutaneous 
flaps. 

It  has  always  been  held  that  the  principal  obstacle  to  the 
closure  of  a  fistula  is  the  frequent  passage  of  urine  through 
it,  and  although  this  has  been  occasionally  questioned,  espe- 
cially with  reference  to  normal,  unaltered  urine,  it  is  still 
considered  one  of  the  principal  indications  to  prevent  this 
passage.  The  choice  lies  between  three  methods  :  1st.  In- 
troducing a  catheter  and  drawing  off"  the  urine  as  often  as 
it  becomes  necessary  to  empty  the  bladder ;  2d,  tying  in  a 
catheter ;  3d,  establishing  a  free  passage  for  the  urine  at 
some  point  on  the  proximal  side  of  the  fistula.  Each 
method  is  open  to  serious  objections ;  the  frequent  passage 
of  the  catheter  is  calculated  to  disturb  the  adjustment  of  the 
flaps,  stretch  the  sutures,  and  irritate  the  urethra ;  and, 
moreover,  a  small  quantity  of  urine  is  sure  to  escape  through 
the  canal  beside  or  behind  it.  A  catheter  retained  in  the 
urethra  for  several  days  is  even  worse ;  as  Ducamp^  pointed 
out  more  than  fifty  years  ago,  it  violates  the  two  conditions 
necessary  to  the  cicatrization  of  every  wound,  moderate 
degree  of  inflammation  and  of  humidity,  by  irritating  the 
canal,  provoking  an  excessive  floAv  of  mucus,  and  acting 
upon  the  wound  itself  as  a  pea  does  in  an  issue.  After  tAVO 
or  three  days  at  the  latest  it  not  only  fails  to  remove  the 
urine  as  fast  as  it  collects  in  the  bladder,  but  actually 
favors  its  escape  alongside  and  through  the  wound.  It 
excites  cystitis  of  the  vesical  neck,  and  sooner  or  later  gives 

*  Traite  des  Retentions  d'Urine,  1825,  p.  237;  quoted  by  Verneuil. 


U  RET  11  HAL    FISTLIL/K.  413 

rise  to  tlic  com])le\'  of  symptoms  known  as  urinary  fever. 
In  short,  it  is  not  only  ineflicient  after  tlic  first  day  or  two, 
but  is  positively  lianiifiil.  The  ohjeetions  to  the  third 
method,  uidess  ])erineal  fistula  exist  and  ean  l)e  sidliciently 
enlari!;ed,  are  that  as  usually  ])raetised  it  involves  a  eonsider- 
able  wound  in  the  perineum,  which  may  itself  give  rise  to  a 
fistula  more  obnoxious  than  that  which  it  is  designed  to  cure, 
and  that  by  destroyiuL!;  the  integrity  of  the  sj)ongy  tissue  of 
the  bulb  it  causes  dribbling  and  im])erfect  ejaculation  of  the 
last  of  the  urine.  Recent  experience,  however,  indicates 
that  a  catheter  can  be  safely  passed  through  the  anus  and 
the  recto-vesical  wall  close  behind  the  prostate,  and  the  blad- 
der drained  through  it  for  several  days  Avithout  danger  of 
establishing  a  recto-vesical  fistula ;  and  if  on  further  trial 
this  should  prove  to  be  the  case,  the  indication  in  (|uestion 
can  be  more  satisfactorily  met  in  this  way  than  by  any  of 
the  other  methods. 

Urcthrorapliy. — This  term  is  applied  to  the  simple  ap- 
proximation of  the  sides  of  a  fistula  after  they  have  been 
pared.  VerneuiP  considers  the  method  applicable  to  all 
circular  fistuh^  not  more  than  one-fifth  of  an  inch  in  diam- 
eter if  the  surrounding  tissues  are  thick,  and  also  to  ob- 
long fistuUe  of  much  greater  size  when  their  long  axis  is  in 
the  median  line  and  their  sides  can  be  easily  brought 
together.  lie  thinks  the  numerous  failures  which  have  fol- 
lowed the  use  of  the  operation  have  been  caused  by  a  lack 
of  attention  to  details,  and  he  suggests  that  the  paring  of 
the  edges  should  be  obliciue  so  as  to  give  the  fistula  the  form 
of  a  funnel  with  its  apex  at  the  opening  into  the  urethra, 
the  mucous  membrane  of  which  should  not  be  included  in 
the  paring.  Fine  metallic  sutures  should  be  used,  applied 
at  short  intervals,  not  penetrating  to  the  canal  of  the  urethra, 
and  tied  over  a  leaden  plate  on  the  surface.  The  line  of 
reunion  should  be  longitudinal,  not  transverse,  and  if  pri- 
mary union  is  not  obtained  the  sutures  should  be  retained 
to  favor  secondary  union.  During  the  operation  a  sound 
should  be  kept  in  the  urethra  in  order  that  the  canal  may 
have  its  full  size. 

^  Cliirurgie  lleparatrice,  p.  696, 
35* 


414      OPERATIONS   ON  GENITO-URIN  A  RY  ORGANS, 

TJrethro'plasty . — The  methods  that  have  been  suggested 
and  emplo^'ed  have  been  very  numerous,  but  most  of  them 
count  more  failures  than  successes.  This  is  especially  true 
of  those  by  which  longitudinal  or  transverse  flaps  have  been 
dissected  up  on  opposite  sides  of  the  fistula  and  brought 
together  by  their  edges  across  its  centre,  for  the  tissues  are 
usually  too  thin  to  afford  a  sufficiently  broad  surface  of  coap- 
tation, and  the  urine  finds  its  way  at  once  through  the 
wound.  It  has  been  proposed  to  overcome  the  latter  ob- 
stacle to  union  by  passing  a  piece  of  thin  India-rubber 
under  the  flaps  (Fig.  252),  but  it  is  doubtful  if  the  presence 


Fig.  252. 


Fig.  253. 


Urethroplasty. 


Urethroplasty.     Nelaton. 


of  the  foreign  body  would  not  have  a  more  unfavorable 
eff'ect  upon  the  thin,  delicate  flaps  than  the  urine  which  it  is 
intended  to  keep  away. 

Nelaton  s  Method. — Nelaton  pared  the  edges  of  the  fistula 
and  dissected  up  the  skin  subcutaneously  for  about  an  inch 
around  it  by  entering  the  knife  through  a  short  transverse 
incision  below  it  (Fig.  253).     The  skin  thus  liberated  was 


URETHRAL    FISTULA.  415 

pinched  up  in  u  longitudinal  fold  along  the  median  line,  and 
fixed  in  this  position  by  twisted  or  quilled  sutures. 

Reyfmrd  made  the  dissection  through  the  fistula,  thus 
avoiding  the  transverse  incision  of  the  skin.  Dieffcnbach 
and  Di'lore  employed  a  similar  method,  but  instead  of  dis- 
secting up  the  skin  subcutaneously  they  raised  two  longitu- 
ilinal  or  transverse  flaps  and  fastened  them  together  by  their 
raw  under  surfaces  (not  edges)  in  the  centre,  the  former 
passing  his  sutures  through  a  leather  splint  on  each  side,  the 
latter  applying  them  in  three  rows,  one  above  the  other. 

Delpech  and  AUiot  dissected  up  a  single  flap,  drew  it 
entirely  across  the  fistula,  and  fastened  it  to  a  raw  surface 
prepared  upon  the  opposite  side. 

Sir  Astley  Coo-per  cut  away  the  skin  in  such  a  manner 
as  to  leave  a  raw  surfiice  of  quadrilateral  form  with  the  fis- 
tula in  its  centre,  and  then  covered  it  with  a  flap  of  the 
same  shape,  taken  from  the  scrotum  by  the  Indian  method 
of  autoplasty. 

Arlaud^  obtained  a  complete  success  in  a  remarkable 
case,  where  the  urethra  had  been  completely  divided  just 
in  front  of  the  peno-scrotal  angle,  and  its  two  cut  ends  were 
nearly  an  inch  apart,  by  adapting  a  method  previously  em- 
ployed by  Roux  to  close  a  fistula  in  the  trachea.  The 
principle  is  the  same  as  in  Delpech's  method,  the  difference 
in  detail  being  that  two  flaps  are  used  instead  of  only  one ; 
the  second  one,  that  which  has  its  cutaneous  surface  pared, 
being  drawn  under  the  first. 

Two  transverse  flaps,  one  in  front  of  the  fistula,  the  other 
behind  it,  were  marked  out  by  longitudinal  incisions  four 
centimetres  apart ;  the  anterior  one  was  dissected  up  for  a 
distance  of  two  centimetres  toward  the  glans,  and  the  pos- 
terior one  dissected  back  over  the  scrotum,  until  it  could  be 
easily  drawn  forward  far  enough  to  cover  the  fistula  entirely. 
The  anterior  portion  of  the  cutaneous  surfoce  of  the  second 
(scrotal)  flap  was  then  thoroughly  pared,  the  flap  drawn 
forward  so  as  to  cover  the  fistula,  and  the  anterior  flap  drawn 
back  over  the  other  and  fastened  there  by  four  points  of 
twisted  suture  and  one  serre-fine. 

^  Bull,  de  la  Societe  de  Chiriirgie,  1857,  p.  550,  and  Yerneuil's 
Chirurgie  Reparatrice,  p.  654. 


416      OPERATIONS    ON   G  EN  ITO- U  RI  N  A  R  Y  ORGANS. 

Sedillot  dissected  up  a  small  flap  on  each  side,  its  base 
adjoining  the  edge  of  the  fistula,  its  free  border  directed 
outward,  reversed  and  united  them  by  their  free  borders  in 
the  median  line  (their  epithelial  surfaces  directed  inward), 
and  broufj-ht  the  sutures  out  throuo-h  the  meatus.  The  raw 
surface  of  the  flaps  was  then  covered  by  a  tliird  flap  trans- 
ferred by  the  Indian  method,  or  by  sliding. 

Riyaud  closed  a  large  fistula  at  the  peno-scrotal  angle 
by  the  method  already  described  as  Nekton's  method  of 
treating  epispadias.  He  took  a  quadrilateral  median  flap 
from  the  scrotum,  its  base  adjoining  the  fistula,  turned  it 
forward  over  the  fistula,  and  covered  its  raw  surface  with  two 
flaps  t^ken  from  the  sides  and  drawn  together  to  meet  in  the 
median  line. 

Theopliile  Anger  has  likewise  proposed  to  close  urethral 
fistulge  by  the  method  he  employed  so  successfully  in  a  case 
of  hypospadias;  and 

Scymanowski^  reports  a  success  obtained  by  a  method 
which  diff"ered  but  slightly  from  Anger's.  He  made  the 
flaps  much  longer  than  the  fistula,  and  freshened  the  cutane- 
ous surface  of  the  reversed  flap  by  blistering  it,  so  that  it 
could  unite  with  the  raw  surface  upon  which  it  Avas  laid. 

Dr.  McBurney^  by  the  use  of  methods  similar  to  the  last 
named,  has  obtained  a  number  of  brilliant  successes  in  ure- 
thral fistula  and  hypospadias ;  several  of  the  cases  are  re- 
ported in  the  proceedings  of  the  New  York  Surgical  Society 
between  1881  and  1884.  In  cases  in  which  previous  opera- 
tions had  failed  and  had  left  cicatricial  tissue  about  the  open- 
ino;  he  soug-ht  to  close,  he  first  removed  the  cicatricial  tissue 
and  supplied  its  place  with  flaps  taken  from  the  adjoining 
skin.  To  close  the  openings  he  used  flaps  similar  to  Anger's 
(Fig.  250),  leaving  the  epidermis  upon  the  surface  of  the 
one  first  turned  in  over  an  area  corresponding  exactly  to  the 
opening,  and  freshening  with  the  knife  all  the  remaining 
portion  of  its  surface.  He  also  dissected  up  for  a  line  or 
two  the  anterior  edge  of  the  central  unfreshened  portion  and 
tucked  it  under  the  freshened  anterior  margin  of  the  opening. 

1  Handbuch  der  Operativen  Chirurgie,  1870. 


EXTERNAL    PERINEAL    URETHROTOMY.       417 


Fig.  2' 


EXTERNAL  PERINEAL  URETHRO- 
TOMY. 

A.  With  a  Guide. — Prof.  Syme, 
who  introduced  this  operation,  em- 
ployed as  a  guide  a  staff,  the 
straight  portion  of  which  was  of 
full  size,  and  its  curved  portion 
much  smaller  and  grooved  on  the 
convexity.  The  change  from  the 
full  to  the  small  size  w'as  abrupt, 
not  gradual  (Fig.  254).  This 
instrument  has  been  superseded,  in 

Fig.  254. 


Syme's  staff  for  perineal  section. 

the  United  States  at  least,  by  the 
tunnelled  instruments  introduced 
bv  Prof.  Van  Buren.^  which  are 
passed  into  the  bladder  over  a  fine 
whalebone  bougie  as  a  guide,  the 
beak  of  the  instrument  being 
bridged  over  or  drilled  out  for  a 
distance  of  about  one-quarter  of 
an  inch,  so  that  it  can  be  slipped 
over  the  bougie  (Fig.  255).  If  a 
Syme's  staff  or  a  tunnelled  catheter 
cannot  be  had,  any  instrument  may 
be  used  which  can  be  got  into  the 
bladder,  but  it  is  a  great  advantage 
to  be  able  to  pass  a  fidl-sized  in- 
sti-ument  step  by  step  as  the  stric- 
ture is  divided. 

The  patient  is  placed  in  the  litho- 


Tunnelled  instrument  and  whale- 
bone suide. 


^  Van  Buren  and  Keyes,  Geni to-Urinary  Diseases,  p.  127. 


418      OPERATIONS   ON   GENITO-U  R I X  A  R  Y   ORGANS 


tomy  i:)Osition  (dorsal  decubitus,  thighs  flexed  upon  the 
abdomen,^  ankles  made  fast  to  the  wrists),  the  perineum 
shaved,  the  Avhalebone  guide  introduced  into  the  bladder,  a 
tunnelled  silver  catheter  of  full  size,  grooved  on  the  con- 
vexity, passed  down  over  it  to  the  stricture  and  confided  to 
an  assistant,  who  also  draws  the  scrotum  forward  out  of  the 
way.     An  incision,  varying  in  length  according  to  the  posi- 

FiG.  256. 


•  Clover's  cratch,  for  operations  upon  the  perineiini 

tion  of  the  stricture,  is  made  in  the  median  line,  and  the  end 
of  the  catheter  exposed.  If  the  stricture  is  deeply  placed 
the  sides  of  the  incision  must  now  be  held  apart  by  means  of 
two  stout  ligatures  passed  through  them,  one  on  each  side, 
while  the  guide  is  carefully  followed  from    before  backward 

^  A  convenient  method  of  keeping  the  thighs  flexed  is  to  pass  a 
stout  cane  under  the  knees  and  fasten  it  with  a  cord  or  roller  bandage 
passed  from  ore  end  around  the  back  of  the  patient's  neck  to  the  other 
end.  An  instrument  has  been  specially  constructed  for  the  purpose 
(Fig.  256),  but  a  stout  stick  does  very  well. 


EXTERNAL    PERINEAL    URETHROTOMY.      419 

with  sliort  cjiutiuus  strokes  of  tlie  knife  in  tlie  median  line, 
and  the  eatheter  ])ushed  along  as  the  route  is  opened,  until 
the  ])Osterior  limit  of  the  stricture  having  been  passed,  it 
sli])s  into  the  bladder.  Care  must  be  taken  not  to  divide  the 
whalebone  guide  by  a  careless  stroke  of  the  knife. 

If  Syme's  staft'  is  used,  the  incision  is  carried  down  until 
the  groove  in  the  curve  of  the  staff  can  be  felt  by  the  finger; 
the  handle  of  the  staff  is  then  grasped  with  the  left  hand, 
the  point  of  a  narrow^  bistoury  passed  into  the  groove  behind 
the  stricture,  and  the  latter  divided  by  cutting  from  behind 
forward. 

Any  bands  that  are  found  on  the  roof  of  the  urethra  must 
be  divided,  and  a  full-sized  steel  sound  passed  to  make  sure 
that  the  stricture  has  been  thoroughly  relieved. 

B.  Without  a  Guide. — The  cases  are  very  rare  in  which 
a  filiform  whalebone  bougie  cannot  be  passed  through  a 
stricture  which  allows  urine  to  pass,  and  consequently  ex- 
ternal urethrotomy  without  a  guide  is  not  often  required. 
The  patient  is  placed  in  the  lithotomy  position,  the  perineum 
shaved,  and  a  full-sized  catheter  passed  down  to  the  stricture 
and  confided  to  an  assistant,  who  also  draws  the  scrotum 
forward,  keeping  its  raphe  exactly  in  the  median  line.  An 
incision,  two  and  a  half  to  three  inches  long,  is  made  in  the 
median  line,  and  the  end  of  the  catheter  exposed  by  open- 
ing the  uretlira  one-quarter  of  an  inch  in  front  of  the  stric- 
ture. The  catheter  is  then  partly  withdrawn,  the  sides  of 
the  wound  held  widely  apart  by  means  of  stout  ligatures 
passed  through  them,  and  an  effort  made  to  pass  a  fine  probe 
or  whalebone  bouo;ie  throucrh  the  stricture  from  before  back- 
wards  ;  if  the  effort  succeeds,  the  operation  becomes  one 
*'witli  a  guide,"  and  is  completed  as  before  described.  If 
the  probe  can  be  passed  for  only  a  short  distance,  a  line  or 
two,  the  tissues  are  divided  upon  it,  and  the  attempt  renewed 
until  the  canal  behind  the  stricture  is  reached. 

If  these  efforts  fail  entirely,  the  urethra  must  be  sought 
for  behind  the  stricture — a  most  difficult  task  unless  a  peri- 
neal fistula  exists  through  which  a  guide  can  be  passed  into 
the  bladder,  or  unless  this  portion  of  the  urethra  is  distended 
with  urine  and  can  be  punctured  in  the  median  line.     Van 


420      OPERATIONS   OX  GE  NTTO-U  RI N  A  R  Y  ORGANS. 

Burcn  and  Keycs^  recommend  that  the  surgeon  should  feel 
for  the  hole  in  the  triangular  ligament,  and  cut  into  it  through 
the  fibrous  mass  by  repeated  strokes  with  the  knife,  always 
in  the  median  line.  Others  prefer  to  pass  the  index  finger 
of  the  left  hand  into  the  rectum,  place  it  against  the  apex  of 
the  prostate,  and  continue  the  dissection  backward  with  a 
view  to  opening  the  urethra  at  that  point.  When  this  has 
been  accomplished,  a  sound  is  passed  from  Ijehind  forward 
to  the  posterior  fiice  of  the  stricture,  and  the  latter  divided 
as  thoroughly  as  possible  between  the  two  sounds. 

If  the  stricture  lies  in  front  of  the  triangular  ligament 
the  centre  of  the  arch  of  the  pubes  is  an  invaluable  guide, 
toward  which  the  incisions  should  be  constantly  directed. 

Perineal  Urethrotomy  for  Exploration  of  the  Bladder 
(Thompson). — The  instruments  needed  are  a  median  grooved 
staff  and  a  lonor  straight,  narrow-bladed  knife,  with  the  back 
blunt  to  the  point.  Having  placed  the  left  index-finger  in 
the  rectum  and  introduced  the  staff,  the  knife  is  introduced, 
edge  upward,  about  three-quarters  of  an  inch  above  the  anus, 
with  or  without  a  small  preliminary  incision  of  the  skin, 
until  the  point  reaches  the  staff  about  the  apex  of  the  pros- 
tate, where  it  divides  the  urethra  for  half  an  inch,  and  is 
then  drawn  out,  cutting  upward  a  little  in  the  act,  but  so  as 
to  avoid  any  material  division  of  the  bulb.  The  index-finger 
is  then  slowly  passed  into  the  bladder  through  the  wound  as 
the  staff  is  withdrawn,  and  the  interior  of  the  bladder  ex- 
plored with  the  aid  of  firm  pressure  above  the  pubes  with  the 
other  hand. 

EXSTROPHY  OF  THE  BLADDER. 

The  first  operation  for  the  relief  of  this  deformity  was 
performed,  according  to  Gross,  by  Prof.  Pancoast,  of  Phila- 
delphia, in  1858;  according  to  Erichsen,  by  Dr.  Daniel 
Ayres,  of  Brooklyn,  in  1859.  The  deformity  is  much  more 
frequent  in  males  than  in  females,  and  the  operative  indi- 
cation is  to  cover  in  as  much  as  possible  of  the  exposed 
mucous  membrane  and  fiicilitate  the  adaptation   of  a  urinal 

^  Diseases  of  the  Genito-Urinary  Organs  with  Syphilis,  p.  125. 


EXSTROPHY    OF    TTTK    BLADDER 


421 


by  making  the  urine  es('a])e  througli  a  comparatively  small 
openino;;  for,  as  the  s})liini*ter  cannot  be  restored,  tliere  will 
always  be  incontinence.  The  method  eni])loye(l  is  the  same 
as  Nelaton's  for  epispadias:  a  tegumentary  ilap  is  raised 
from  the  abdomen  above  the  bladder,  reversed  so  as  to  cover 
the  latter,  and  then  covered  itself  in  tm-n  by  lateral  flaps, 
one  from  each  side. 

The  first  flap  (Fig.  257)  should  be  square,  its  base  ad- 
joining and  slightly  broader  than  the  upper  margin  of  the 
opening,  its  length  should  be  suflicient  to  cover  in  the  blad- 
der completely  when  turned  down  over  it.  A  pyriform  flap 
is  dissected  up  on  each  side,  its  breadth  e(|ual  to  the  length 


Fig.  257. 


Fig.  2.58. 


Wuixrs  operation  for  exstrophy  of  the  bladder. 
Incisioi].s. 


Fhvps  in  place. 


of  the  first  flap,  and  its  base  directed  downward  and  inward, 
as  shown  in  Fig.  257,  or  downward  and  outward  so  as  to 
require  less  twisting  and  include  more  of  the  cutaneous 
branches  coming  from  the  femoral  artery.  These  two  flaps 
are  then  drawn  across  the  reversed  umbilical  flap,  meeting 
in  the  median  line,  and  are  fastened  to  each  other  with 
twisted  sutures,  the  pins  including  a  portion  of  the  thickness 
of  the  uml)ilical  flap  also,  so  as  to  keep  the  raw  surfaces  in 
contact  (Fig.  25S). 

The  edges  of  the  gaps  left  by  the  removal  of  the  flaps  are 
drawn  together  as  well  as  possible  with  twisted  and  wire 
sutures,  broad    sti'ips  of  adhesive    plaster   applied  to  give 

36 


422      OPERATIC XS   ox   GENITO-URINARY   ORGANS. 

support  and  relieve  tension,  and  the  patient  kept  in  lied  in  a 
sitting  posture  with  the  knees  drawn  up.  The  sutures  may 
be  removed  at  the  end  of  a  week. 


CATHETERIZATION  (WITII  CURVED    METAL  CATIIETER). 

The  obstacles  to  the  passage  of  a  catheter,  exclusive  of 
stricture  and  of  false  passage,  are  found  either  at  the  trian- 
gular ligament  in  the  membranous,  or  in  the  prostatic  por- 
tion of  the  urethra.  As  the  fixed  portion  of  the  canal  begins 
anteriorly  at  the  opening  in  the  subpubic  or  triangular  liga- 
ment, the  flaccid  pendulous  portion  in  front  of  this  point 
may  be  carried  aside  if  the  catheter  is  held  improperly,  and 
doubled  upon  itself  in  front  of  the  beak  of  the  instrument, 
thus  forming  a  sort  of  pouch  or  cul-de-sac  which  arrests  the 
progress  of  the  catheter.  This  difficulty  is  overcome  by 
drawing  the  penis  gently  up  the  shaft  of  the  instrument  so 
as  to  sti'aighten  out  the  portion  of  the  canal  yet  to  be  tra- 
versed, and  by  keeping  the  beak  in  the  median  line  and 
making  it  follow  the  roof  rather  than  the  floor  of  the  urethra, 
so  as  to  avoid  especially  the  normal  pouch-like  dilatation 
found  on  the  under  side  just  in  front  of  the  opening  in  the 
ligament. 

The  obstacle  in  the  membranous  portion  is  caused  by  the 
spasmodic  contraction  of  the  muscles  which  envelop  this 
part  of  the  canal.  The  nature  of  the  obstruction  is  recog- 
nized by  the  tight  grasp  of  the  instrument  by  the  muscles, 
the  quivering  of  the  fibres  transmitted  through  it  to  the 
hand  of  the  suro-eon,  and  bv  the  knowledge  of  the  fact  that 
the  instrument  has  reached  this  part  of  the  canal  where 
organic  obstacles  do  not  often  exist.  The  difficulty  is  over- 
come bv  makins:  o;entle  pressure  with  the  beak  of  the  ca- 

_«.  CGI 

theter  in  the  proper  direction,  so  as  to  tire  out  the  muscles. 

The  most  serious  obstacle  is  found  in  the  prostatic  portion, 
and  is  due  either  to  inflammatory  swelling  of  the  mucous 
membrane  or  of  the  gland  (abscess  of  the  prostate),  or.  much 
more  commonly,  to  senile  change  in  the  shape  and  size  of 
this  organ.  A  description  of  the  nature  of  these  changes 
and  lesions  does  not  come  within  the  scope  of  this  work,  and 
the  reader  is  referred  for  them  to  special  treatises  upon  the 


CATIIETEKIZATION.  42o 

snl)j('ct.  It  is  siinicient  lierc  to  say  that  in  tlic  foniiei-  case 
the  iiitlainmation  must  he  re(hu*0(l  or  the  ahscess  evacuated 
secunduni  artem^  or,  tailing  tliis,  the  hhidder  must  be  punc- 
tured above  the  pubes,  or  througli  the  rectum.  In 
tlie  other  case,  catlieters  of  diiferent  curves  should  ^^^-  2-''-^- 
be  tried,  such  as  ^Fott's  long  catheter  of  large  curve,  ^ 
or  Mercier's  single  or  double-elbowed  (•atheter  (Fig,  V 
259).  It  is  also  well  to  pass  the  forefinger  of  the 
left  hand  into  the  rectum  to  make  sure  that  the 
catheter  has  entered  at  the  apex  of  the  prostate,  and 
that  it  has  not  passed  o'ut  of  the  canal  into  a  false 
passage,  and  to  try  to  lift  its  beak  over  the  obstacle 
by  making  direct  pressure  upon  the  curve  in  front 
of  the  prostate,  while  the  handle  is  simultaneously 
depressed. 

If  these  means  fail,  and  soft  instruments  of  gum 
or  vulcanized  rubber  cannot  be  introduced,  the 
bladder  must  be  punctured. 

Passaf/e  of  the   Catheter. — The  patient  having 
been  l)rouglit  to  the  side  of  the  bed  or  placed  upon 
a  lounge,  the  surgeon,  standing  on  one  side,  pre- 
ferably the  left,  separates  the  lips  of  the  meatus 
with  the  thumb  and  forefinger  of  the  left  hand,  in- 
troduces the  beak  of  the  catheter,  previously  well 
warmed  and  oiled,  and  passes  it  down  to  the  peno- 
scrotal an^ijle,  holding;  the  shaft  of  the  instrument 
parallel  to  the  groin.     He  then  sweeps  the  handle 
around  to  the  median  line  of  the  abdomen,  keeping 
it  close  to  the  surface,  draAVS  the  })enis  gently  up  the 
shaft,  and  presses  the  instrument  bodily  downward 
toward  the  feet ;  as  soon  as  the  beak  reaches  the 
lower  border  of  the  symphysis  he  draws  the  scrotum 
up  and  presses  the  catheter   gently  onward,   still      M 
holding  it  parallel  to  the  body,  and  then  when  the     *^ 
beak    has    closely  approached  or  enj^aged  in    the   ^^';'"^"'';* 
opening  in  the   triangular   ligament  he   gradually    catheter 
raises  the  handle,  brings  it  forward  in  the  median 
line,  and  depresses  it  between  the  thighs.     Failure  to  enter 
the  opening  in  the  trituigular  ligament  is  in<licated  by  the 
buliiini:  of  the  curve  of  the  instrument  in  front  of  the  sym- 
physis,  its  rebound  when  the  slight  pressure  on  the  handle 


424      OPERATIONS   ON  GENITO-U  RIN  AR  Y   ORGANS. 

is  removed,  and  the  mobility  of  the  beak  when  the  handle 
is  gently  rotated  about  its  longitudinal  axis. 

As  the  shaft  passes  the  vertical  line  the  root  of  the  penis 
and  the  integument  covering  the  symphysis  should  be  pressed 
down  with  the  palm  of  the  right  hand  laid  broadly  upon  it, 
so  as  to  stretch  the  suspensory  ligament. 


PUNCTURE  OF  THE  BLADDER. 

Above  the  Pubes. — The  only  instrument  required  is  a 
straight,  or,  better,  a  curved  trocar  and  canula,  the  trocar 
having  a  groove  in  its  side  Avhich  permits  a  small  stream  of 
urine  to  pass  as  soon  as  the  bladder  is  reached.  The  sur- 
geon satisfies  himself  by  percussion  that  the  distended  blad- 
der rises  well  above  the  pubes,  and  then  making  the  skin 
tense  with  the  thumb  and  fingers  of  his  left  hand,  he  plunges 
in  the  trocar  about  an  inch  above  the  symphysis  pubis  in 
the  median  line,  the  concavity  of  the  instrument  turned 
toward  the  bone. 

Some  surgeons  prefer  to  make  a  preliminary  incision  in 
the  median  line,  and  others  (Holmes)  even  continue  the  use 
of  the  knife  until  the  bladder  can  be  felt  at  the  bottom  of 
the  wound. 

Under  the  Pubes. — Voillemier  once  punctured  below  the 
pubes,  because  the  bladder  was  so  contracted  that  he  did 
not  think  it  safe  to  approach  it  from  above,  and  the  prostate 
so  large  that  its  upper  border  could  not  be  reached  through 
the  rectum.  The  penis  was  drawn  downward,  and  a  curved 
trocar,  with  its  concavity  directed  upward,  entered  close 
under  the  symphysis. 

Throwjh  the  Rectum.  A.  From  without  inwards. — The 
patient  having  been  anaesthetized,  the  surgeon  passes  his 
left  forefinger  into  the  rectum  and  places  its  tip  against  the 
posterior  face  of  the  prostate  between  the  seminal  vesicles. 
He  then  passes  the  trocar  along  the  finger  and  plunges  it 
into  the  bladder  with  a  sharp,  vigorous  push,  so  as  to  insure 
its  passage  through  the  wall  and  its  penetration  to  a  suffi- 
cient depth.     After  Avithdrawal  of  the  trocar  the  canula  is 


PUNCTURE    OF    THE    15LADUEK.  425 

tied  in,  or  a  }iiun  catheter  is  passed  through  it  to  retain  it  in 
position. 

B.  Mi-Burneys  Method. — I)r.  McBiiniey^  has  intro- 
duced a  very  convenient  nietliod  of  pa.ssing  the  catlieter 
from  within  the  bladder  out  through  tlie  anus.  A  metal 
button  rescmblinir  the  head  and  part  of  the  shaft  of  a  me- 
dium sized  round-headed  screw,  and  hollowed  out  for  a 
short  distance  at  its  small  end,  is  inserted  into  the  end  of  a 
soft  rubber  catheter  and  tied  fast  to  it  (Fig.  '2 GO).     A  well- 

'     Fig.  260. 


Puncture  of  the  bladder  through  the  rectum.     McBurney. 

oiled  staff,  .^^lightlv  curved  at  the  beak,  is  passed  through  the 
eye  of  the  catheter  and  its  point  engaged  in  the  hollow  end 
of  the  metal  button.  The  catheter  is  stretched  along  the 
staff,  so  as  to  keep  the  point  of  the  latter  firmly  fixed  in  the 
button,  and  passed  into  the  bladder. 

The  index  and  middle  fingers  of  the  left  hand  are  then 
passed  into  the  rectum,  the  posterior  border  of  the  prostate 
and  the  seminal  vesicles  reconnized,  the  catheter  reversed 
so  as  to  press  the  button  down  in  the  median  line  between 
the  two  fingers  in  the  rectum  and  then  confided  to  an 
assistant  who  holds  it  steadily  in  place  while  the  surgeon 
passes  a  blunt-pointed  bistoury,  the  blade  of  which  is 
wrapped  to  within  an  inch  of  the  point,  into  the  rectum  be- 
tween his  fingers,  and  cuts  through  the  intestinal  and  blad- 
der walls  upon  the  button.  As  soon  as  the  button  slips 
through  into  the  rectum  the  staff"  is  withdrawn  and  the  other 
end  of  the  catheter  is  drawn  into  the  bladder  by  bringing 
the  button  out  through  the  anus.  Care  must  be  taken  not  to 
draw  it  too  far,  that  is,  entirely  through  into  the  rectum,  and 

^  Oral  communication,  1877. 
36* 


426      OPERATIONS  ON   GENITO-URIN AR Y   ORGANS. 

if  there  is  any  urine  present  its  escape  through  the  catheter 
as  soon  as  the  eye  enters  the  bladder  tells  the  surgeon  when 
to  stop. 

Dr.  McBurney  at  first  used  a  button  with  a  conical  head, 
which  Dr.  Thomas  T.  Sabine  modified  by  rounding  it  and 
adding  the  groove  shown  in  the  figure.  By  keeping  this 
groove  in  the  antero-posterior  plane  and  cutting  into  it  as 
into  the  groove  of  a  lithotomy  staff  the  execution  of  the 
operation  is  facilitated.  Dr.  Sabine  also  makes  the  incision 
with  a  o;um  lancet  instead  of  a  o-uarded  bistoury. 


LITHOTRITY. 

The  modern  lithotrite  is  a  steel  instrument  consisting  of  a 
straiojht  shaft  eleven  inches  in  lenojth,  havins;  at  one  end  a 
"beak"  about  an  inch  lonoj  inclined  at  an  angle  of  from 
110°  to  130°,  and  at  the  other  a  cylindrical  roughened 
handle  containing  a  screw.  It  is  composed  throughout  of 
two  parts,  one  fitting  accurately  in  a  deep  groove  in  the 
other,  and  having  at  the  handle  a  male  screw  which  can  be 
thrown  into  and  out  of  gear  by  means  of  a  button  upon  the 
other  part.  While  trying  to  catch  a  stone  the  screw  should 
be  out  of  gear,  in  order  that  the  male  blade  may  be  advanced 
and  withdrawn  more  rapidly,  but  Avhen  the  stone  has  been 
fiiirly  caught  the  button  must  be  pressed  back  and  the 
screw-power  used  to  crush  it. 

Many  different  patterns  have  been  proposed  for  the  beak 
or  jaws  with  the  view  either  of  securing  the  thorough  pul- 
verization of  the  fragments,  or  of  preventing  the  clogging  of 
the  instrument  by  the  impaction  of  the  mortar-like  detritus 
between  the  jaws.  The  latter  difficulty  can  be  overcome  by 
leaving  the  jaw  of  the  female  blade  entirely  open,  that  is, 
with  a  large  fenestra  extending  from  side  to  side  and  from 
the  extremity  of  the  beak  to  its  angle,  and  by  making  the 
male  blade  long  enough  to  allow  its  jaw  to  be  passed  entirely 
through  the  female  one  and  even  to  project  beyond  its  con- 
vex surface.  In  its  simplest  terms,  then,  the  jaws  should 
consist  of  two  parallel  bars,  one-fourth  of  an  inch  apart, 
between  which  a  third  one,  fitting  loosely  in  the  gap,  can  be 
forced.     Of  course,  the  male  jaw  must  not  be  allowed  to  pro- 


LITHOTKITY. 


427 


ject  beyond  tlio  convex  surface  of  tlie  female  one  during  its 
passage  through  the  uretlira. 

A  small  fenestra  at  the  angle  of  tlie  beak  will  not  prevent 
cloiTiiinii,  althoudi  it  may  diminish  it  if  theie  is  a  cor- 
responding  projection  at  the  heel  of  the  male  jaw,  as  m 


CO 

d 
1—1 


(M 

CO 

6 


Fig.  263 ;  and  it  is  open  to  the  very  serious  objection  that 
it  may  lodge  a  sharp  angular  fragment,  which,  projecting 
beyond  its  edges,  will  lacerate  the  neck  of  the  bladder  and 
the  floor  of  the  urethra  during  the  withdrawal  of  the 
instrument. 


428      OPERATIONS   ON   GENITO-URINA  R Y  ORGANS. 

The  arrangement  of  open  spaces  in  the  female  jaw  cor- 
respondino:  to  guttered  projections  or  teeth  upon  the  male 
jaw,  as  in  Reli(juet's  model,  is  entirely  insufficient  to  prevent 
clogging.  The  detritus  packs  across  the  gaps  and  presents 
an  absolute  bar  to  the  closing  of  the  instrument.  Whenever 
such  corresponding  teeth  and  spaces  are  used  they  should  be 
cut  to  fit  each  other  very  loosely,  that  is,  with  a  clear  space 
of  at  least  one  millimetre  between  them. 

Tig.  263. 


"Scoop"  lithotrite. 

For  catching  and  crushing  small  fragments  the  "  scoop" 
lithotrite  is  commonly  used  ;  the  jaw  of  its  female  blade  is 
broad  and  shallow,  with  no  fenestra  or  with  only  a  small  one 
at  its  angle.  The  edges  of  both  jaws  should  be  bevelled, 
and  the  male  considerably  narrower  than  the  female,  so  that 
they  may  be  brought  together  with  the  least  possible  danger 
of  including  a  fold  of  mucous  membrane  between  them. 

Prof.  Bigelow,^  of  Boston,  recommends  an  instrument 
(Figs.  264  and  265)  combining,  as  he  claims,  the  advantages 
of  the  fenestrated  and  the  scoop  lithotrites.  The  female  jaw 
is  shallow,  so  that  small  fragments  are  easily  caught  and 
crushed  in  it,  and  clogging  is  prevented  by  deep  notches 
opening  outward  on  the  sides  of  the  male  jaw  (Fig.  265), 
and  by  a  small  fenestra  at  the  angle  to  provide  for  the  escape 
of  the  detritus  eni^aoied  in  the  o-roove  of  the  female  blade. 
He  also  substitutes  for  the  button  on  the  handle  of  Thomp- 
son's lithotrite  a  mechanism  partly  shown  in  Fig.  264,  by 
whicli  the  screw  can  be  thrown  into  gear  by  a  turn  of  the 
hand  holding  the  end  of  the  male  blade  ;  and,  further,  curves 


*  American  Journal  of  Medical  Sciences,  Jan.  1878. 


L I T  H  O  T  K  I T  Y 


429 


Fio.  2G4. 


the  beak  of  tlic  instrument  to  facilitate  its  passage  throu«rh 
the  prostatic  urethra.      It  must  he  admitted,  however,  tliat 

with  a  soft,  phosphatic  stone  the 
instrument  will  become  impacted; 
and  when  the  stone  is  lar;ie  and  liard 
the  connecting  catch  is  liable  to  be 
torn  away.  I  prefer,  therefore,  the 
instrument  recommended  by  Prof. 
Keyes  (Fig.  262);  it  cannot  clog, 

Fio.  2G5. 


m^ 


1 


Bigelow's  lithutrite. 


and  the  lateral  catch  cannot  be  broken  by  any  force  exerted 
through  the  screw. 

Operation. — The  patient  is  prepared  for  the  operation  by 
diminishing  irritability  <  f  the  bladder,  if  it  exists,  and  by 
having  him  retain  his  urine,  if  possible,  for  an  hour  and 
a  half  or  two  hours  before  the  operation  is  begun.  He  is 
then  placed  upon  his  back,  with  his  hips  raised  upon  a  firm 
pillow  or  cushion  in  order  that  the  stone  may  gravitate  away 
from  the  neck  of  the  bladder,  and  the  surgeon,  standing  at 


430      OPERATIONS   ON  G EN ITO- URINARY   ORGANS. 

his  rio;ht  side,  introduces  the  well-warmed  and  oiled  lithotrite 
in  the  manner  described  for  the  introduction  of  a  catheter. 
Great  care  must  be  taken  not  to  depress  the  handle  too 
soon,  a  mistake  which  is  likely  to  be  made  on  account  of  the 
apparently  great  depth  to  which  the  instrument  has  to  pene- 
trate before  the  bladder  is  reached. 

As  soon  as  the  instrument  has  entered  the  bladder,  it  is 
allowed  to  glide  across  it,  its  shaft  being  held  steadily  in  one 
position,  and  if  the  stone  is  free  it  will  generally  be  touched 
on  the  way  The  surgeon  then  gently  turns  the  beak  away 
from  the  stone,  withdraw^s,  w^ith  his  right  hand,  the  male 
blade  for  a  distance  determined  by  previous  measurement  of 
the  stone,  presses  the  jaw  of  the  female  ])lade  gently  against 
the  floor  and  posterior  wall  of  the  bladder,  rotates  the  beak 
toward  the  stone,  and  closes  the  male  blade  upon  it.  As 
soon  as  the  stone  is  felt  to  be  firmly  caught  the  beak  is  ro- 
tated back  to  the  vertical  position,  and  the  screw  thrown 
into  gear  by  pressing  back  the  button  on  the  handle  with 
the  thumb  of  either  hand.  The  lithotrite,  with  the  stone  in 
its  grasp,  is  then  drawn  away  from  the  posterior  wall  and 
rotated  to  either  side  to  make  sure  that  the  mucous  mem- 
brane is  not  caught  between  its  jaws,  and  then,  grasping 
the  cylindrical  handle  firmly  with  his  left  hand,  he  crushes 
the  stone  by  turning  the  screw  with  his  right,  and  continues 
this  action  until  the  register  upon  the  handle  shows  that  the 
male  blade  has  been  driven  well  home.  The  screw  is  then 
thrown  out  of  gear,  the  male  blade  drawn  back,  the  beak 
turned  again  toward  the  spot  where  the  stone  was  caught, 
and  the  instrument  closed  whether  the  fragments  are  felt  or 
not,  for  it  may  be  confidently  expected  that  they  will  be 
found  there. 

Except  under  ether,  the  crushing  should  not  be  repeated 
more  thnn  three  or  four  times  at  one  sitting,  the  lithotrite 
being  retained  in  the  bladder  for  from  three  to  five  minutes. 
In  all  the  manipulations  care  must  be  taken  not  to  bring  the 
concavity  of  the  jaws  into  contact  with  the  sensitive  neck  of 
the  bladder. 

When  the  stone  is  lodged  close  behind  a  much  enlarged 
prostate,  the  beak  of  the  lithotrite  must  be  completely  re- 
versed and  the  stone  picked  up,  as  it  were. 

The  patient  must  be  kept  in  bed  for  the  twenty-four  hours 


LITHOTRITY. 


431 


following  tlie  operation  ;  and  wlicn  lie  passes  water  he  must 
roll  well  over  upon  his  side  without  raisiii<^  his  shoulders 
from  the  bed. 

Rajyid  Litliotritii  with  Evacuation.  Tjitliolapaxy  (Bige- 
low). — The  method  of  prolonged  erushings  under  ether,  with 
evacuation  of  the  fragments,  introduced  by  Prof.  Bigelow  in 
1878,  has  completely  superseded  the  old  operation  excei)t 
for  very  small  stones  and  in  exceptional  circumstances.  The 
special  instruments  required,  besides  a  lithotrite  which  can 
be  trusted  not  to  impac't,  are  a  washing  bottle  and  straight 
or  curved  evacuating  tubes.  Of  the  fn-mer  there  are  several 
patterns.     Fig.  2GG  represents  Prof.  Bigelow's  last  model, 


Bigelow'^  washing  bottle  and  evacuating  tubes. 

and  Fig.  267  Sir  Henry  Thompson's.  The  evacuating 
tubes  should  be  of  large  size,  say  28  to  -30  of  the  French 
scale,  with  a  very  large  eye,  as  shown  in  Fig.  266.  The 
great  practical  difficulty  in  their  use  is  that  a  large  angular 
fragment  may  lodge  in  the  eye  so  firmly  that  it  cannot  be 


432      OPERATIONS  OX  GENITO-URIN  A  R  Y  ORGANS. 

dislodged  by  the  stream  of  water,  and  will  tear  the  urethra 
as    the    tube    is  withdrawn.     Prof.    Keves    recommends    a 

Fig.  2G7. 


Thompson's  washing  bottle. 


Straight  tube  with  an  open  end,  cut  si^uare,  and  provided 
with  a  central  staft"  having  a  curved  rubber  end  that  fills  the 

Fig.  268. 


Keycs'<  straiiflit  evuciiatiiii?  tii 


orifice  of  the  tube  exactly  and  fiicilitates  its  introduction 
(Fig.  268).  The  limited  use  I  have  made  of  this  tube  has 
been  very  satisfactory. 

Anaesthesia  must  be  employed.     Recently  in  a  few  ope- 


LITHOTRITY.  433 

rations  cocaine  has  been  successfully  used  to  prevent  pain. 
Three  or  four  drachms  of  the  solution  were  thrown  into  the 
empty  bladder  and  one  into  the  urethra.  The  only  pain  felt 
was  in  the  distention  of  the  bladder  in  washing.  The  blad- 
der is  usually  so  sensitive  to  this  distention  beyond  a  certain 
limit  that  patients  will  manifest  pain  even  when  completely 
anesthetized  with  ether,  and  I  do  not  expect  that  cocaine 
will  prove  generally  sufficient. 

If  the  urine  is  turbid,  and  especially  if  it  is  ammoniacal, 
it  should  be  drawn  off  before  the  operation,  and  the  bladder 
thoroughly  washed  with  a  borax  solution  (one  or  two  drachms 
to  the  pint),  of  which  from  two  to  four  ounces  should  be  left 
in  the  bladder  to  facilitate  the  crushing. 

The  stone  is  caucjht  and  crushed  accordinof  to  the  direc- 
tions  already  given,  the  crushings  being  rapidly  repeated  for 
several  minutes.  Then  the  smaller  fragments  are  washed 
out,  and  the  lithotrite  reintroduced ;  and  this  alternation  in 
the  use  of  the  instruments  is  continued  until  the  bladder  is 
emptied.  This  frequent  washing  is  important  because  by 
the  removal  of  the  smaller  fragments  it  is  made  easier  to 
seize  and  crush  the  larger  ones. 

The  washing  is  done  as  follows :  The  washino;  bottle  is 
filled  with  tepid  water,  then  the  tube  is  introduced,  and  as 
soon  as  the  urine  beo;ins  to  flow  throucrh  it  the  bottle  is 
coupled  to  it.  Or  the  coupling  may  be  done  just  before  the 
tube  has  entered  the  bladder,  and  the  air  in  the  tube  allowed 
to  rise  to  the  top  of  the  bottle,  by  turning  the  stop-cock, 
before  the  introduction  is  completed  and  the  washing  is 
begun. 

By  quick  compression  and  relaxation  of  the  rubber  bulb 
the  water  is  rapidly  forced  into  the  bladder  and  drawn  back 
again,  brinorino:  the  fragments  with  it :  these  fragments  sink 

O'OO  o  '  I'll 

to  the  bottom  of  the  bottle  and  are  not  returned  with  the 
returning  stream.  The  amount  of  water  driven  back  and 
forth  at  each  movement  will  vary  w^ith  the  sensitiveness  and 
distensibiUty  of  the  bladder ;  two  or  three  ounces  are  suf- 
ficient to  wash  effectively.  If  the  curved  tube  is  used,  its 
eye  should  be  in  turn  directed  to  different  quarters  of  the 
bladder ;  if  the  straight  tube  with  a  square  end  is  used,  it 
must  be  passed  just  through  the  neck,  and  its  outer  end  well 
depressed  between  the  thighs. 

37 


434      OPERATIONS    ON   G  E  N  I  TO-U  RIX  A  E  Y   ORGANS. 

At  the  close  of  the  operation  the  surgeon  should  place  his 
ear  upon  the  hypogastrium  and  listen  while  washing,  to 
detect  the  click  against  the  tube  of  any  fragments  that  may 
remain.  This  is  a  much  more  delicate  test  than  the  use  of 
the  searcher. 

LITHUTOMY. 

The  anatomy  of  the  perineum  is  sufficiently  well  shown 
in  FiiT.  209  to  render  a  detailed  description  unnecessary. 

Fig.  269. 


Art*rg  of  Corpus  Caverjiosum 
Dorsal  Ariery  of  Pern 


Artery  of  £ulh, 
Intcrmal  I'uJix?  Artery 


Ccu-per'g    ClanJ 


A  Tiew  of  the  position  of  the  viscera  at  the  outlet  of  the  pelvis. 

It  must  be  remembered,  however,  that  the  distance  between 
the  anus  and  the  bulb  diminishes  with  advancing  years,  and 
that  the  diminution  of  the  distance  is  due  to  an  increase  in 


LITHOTOMY 


435 


the  size  of  the  hull).  The  dangers  ineident  to  incision  of 
the  bulb  increase,  therefore,  with  the  difficultv  of  avoidinir 
it.  The  dimensions  of  the  prostate  have  been  studied  with 
much  attention,  and  have  been  the  basis  of  many  of  the 
modifications  of  perineal  lithotomy,  for  it  has  been  held, 
and  still  is  held  by  many,  that  the  incision  should  not  be 
carried  beyond  the  limits  of  the  gland.  The  greatest  radius, 
measuring  from  the  urethra,  is  one  inclined  about  30°  back- 
ward and  downward  from  the  transverse  diameter,  and  in 
the  normal  adult  prostate  this  measures  about  three-r{uarters 
of  an  inch  at  the  largest  part  of  the  gland,  that  which  ad- 
joins the  neck  of  the  bladder.  But,  as  the  diameter  of  the 
prostate  diminishes  as  the  distance  from  the  bladder  in- 
creases, an  incision  which  remains  within  its  limits  at  one 
point  may  extend  far  beyond  them  at  another ;  and  this 
fact,  taken  in  connection  with  the  2;reat  variations  in  the 
size  of  the  gland,  indicates  the  futility  of  attempts  to  regu- 

PiG.  270. 


Inciaion   in  lateral  lithotomy  ;   the  dotted  line:<  mark  \\s,  limits.     A.   Vas  deferens. 
B.  Seminal  vesicle.     C.  Continuation  of  the  capsule  or  prostato-peritoneal  ligament. 

late  the  incision  with  mathematical  precision.  Fortunately, 
the  depth  of  the  incision  is  not  a  measure  of  the  size  of  the 
stone  which  can  be  safely  removed  through  it,  for  the  nor- 
mal dilatability  of  the  neck  of  the  bladder  and  the  prostatic 
portion  of  the  urethra  fto  a  diameter  of  two  centimetres,  ac- 
cording to  Dolbeau)  is  thought  to  be  considerabl}'  increased 
by  even  slight  incisions.  Dupuytren  thought  the  opening 
in  the  prostate  could  be  greatly  enlarged  by  making  an 


436      OPERATIONS   ON   G  E  NITO-U  KIN  A  R  Y   ORGANS, 


oblique  incision  on  each  side  (bilateral  lithotomy),  and  an 
admirable  instrument,  the  double  lithotome  cache  (Fig. 
287),  was  constructed  for  the  purpose,  but  the  gain  has  not 
proved  so  great  as  was  expected. 

By  reference  to  Figs.  270  and  271,  which  show  the  ex- 
tent of  the  incision  of  the  prostate  and  neck  of  the  bladder 
in  lateral  lithotomy,  it  will  be  seen  that  the  limits  of  the 
prostate  are  exceeded  everywhere,  the  capsule  remaining 

Fig.  271. 


Lateral  lithotomy.  Incision  of  the  neck  of  the  bladder  as  seen  from  within.  A  is  a. 
rent  in  the  wall  made  by  the  introduction  of  the  finger.  B  is  an  extension  of  the 
Incision  involving  only  the  mucous  membrane. 

intact,  however,  for  a  distance  of  about  half  an  inch  at  the 
thickest  part  of  the  gland.  The  sulcus  between  the  bladder 
and  the  prostate  is  opened,  and  the  bladder  wall  divided  for 
fully  half  an  inch  in  the  direction  of  the  orifice  of  the  left 
ureter.  These  figures  are  taken  from  a  dissection  of  a 
cadaver  upon  which  lateral  lithotomy  had  been  performed 
for  the  purpose  of  determining  these  points.^ 

If  the  stone  is  large  and  the  tractions  made  with  too  much 
force,  the  neck  of  the  bladder  ma}'  be  torn  off,  but  more 
commonly  the  incision  is  lengthened  by  tearing  at  its  outer 

^  The  operation  was  done  by  a  surgeon  of  large  experience  in 
lithotomy,  and  the  incision  was  made  as  if  for  the  removal  of  a  stone 
one  inch  in  diameter.  The  cadaver  was  that  of  a  mulatto  about 
twenty-five  vears  old. 


LATERAL    LITHOTOMY. 


437 


end,  an  iiccident  wliich  is  much  less  dan<:er(jus  tluin  extend- 
ing  the  incision  with  the  knife  would  be,  for  it  spares  the 
rich  plexus  of  veins  about  the  prostate. 


FiQ.  272. 


Fio.  278.      Fig.  274.      Fio.  27o.     Fio.  276. 


Lithotomy  staff. 


sr: 


I 

Gorget. 


Scoop. 


Lateral  Lithotomy/. — The  instruments  required  are  a  staiF 
with  a  long  curve,  deeply  grooved  on  its  convexity  (Fig. 
272),  a  stout  scalpel  with  a  cutting  edge  of  one  and  one- 

37* 


438      OPERATIONS   OX   GEXITO -U  RIX  A  R  Y  ORGANS 


lialf  inches  (Fig.  273),  a  Blizard's  knife  (Fig.  274),  a  blunt 
gorget  (Fig.  27o)  if  the  patient  is  fat,  a  scoop  (Fig.  276), 
forceps  of  different  patterns  (Figs.  277,  278,  279),  a  syringe 
and  tube  for  washino;  out  fracrments,  and  a  shirted  canula 
(Fig.  280)  to  control  hemorrhage.  The  latter  can  be  readily 
made  by  passing  the  beak  of  a  female  silver  catheter  through 


Fig.  277. 


Figs.  278,  279. 


Fig.  280. 


Sliirtcd  canula 


the  centre  of  a  piece  of  muslin  eight  inches  square,  and 
tying  the  two  firmly  together,  as  shown  in  the  figure.  It  is 
then  introduced  into  the  wound,  the  beak  of  the  catheter  in 
the  bladder,  the  muslin  pouch  tightly  packed  afterwards 
with  pledgets  of  lint,  and  the  whole  kept  in  place  by  a 
T-bandage.  Three  assistants,  at  least,  are  required ;  one 
to  administer  the  anaesthetic,  the  others  to  hold  the  knees 
and  the  staff. 

Operation} — The  patient,  having  had  his  bowels  emptied 

*  Yan  Buren  and   Keves,  Genito-Urinarv  Diseases  and   Svphilis, 
p.  335. 


LATERAL    LITHOTOMY 


439 


by  an  enema,  is  placed  upon  liis  bark,  hi.s  ankles  bound  fast 
to  his  wrists  (Fig.  -^^^1),  the  staft'  introduced,  and  the  stone 
touched  with  it.  It  is  an  absolute  rule  that  if  the  stone 
cannot  be  felt  with  the  staff'  or  a  searcher  after  the  patient 
has  been  etherized  and  placed  upon  the  table,  the  operation 
must  be  postponed.     It  is  not  necessary  that  the  beak  of 

Fig.  28L 


Position  of  patient  and  line  of  incision  in  lateral  lithotomy. 


the  staff  should  rest  upon  the  stone  during  the  operation; 
on  the  contrary,  it  is  better  to  hook  the  staff  up  under  the 
symphysis  so  as  to  keep  it  steady,  with  its  curve  bellied 
out  in  the  median  line  of  the  perineum,  and  the  integument 
stretched  over  it  by  drawing  the  scrotum  up  around  the 
staff. 

The  operator  passes  his  index-finger  into  the  rectum,  and 
satisfies  himself  that  the  staff  enters  at  the  apex  of  the  pros- 
tate and  passes  centrally  through  it,  and  that  the  rectum  is 
empty.  Then  withdrawing  his  finger  he  feels  along  the 
raphe  of  the  perineum  for  the  groove  in  the  staff,  aiding 
himself,  if  necessaiy,  by  depressing  and  raising  the  handle 
several  times. 

Having  found  the  groove  he  confides  the  staff  to  his  chief 
assistant,  enters  the  scalpel  a  little  to  the  patient's  left  of  the 
raphe,  from  one  and  one-quarter  to  one  and  one-half  inches 


440      OPERATIONS  OX   GENITO- U  RIN  A  R  Y   ORGANS. 

in  front  of  the  anus,  and  passes  it  in  almost  parallel  to  the 
rectum  so  as  to  enter  the  groove  about  half  an  inch  in  front 
of  the  apex  of  the  prostate,  guiding  it,  if  he  thinks  best,  by 
keeping  his  left  index-finger  upon  the  prostate  in  the  rectum. 
(If  the  knife  should  be  passed  directly  in  to  the  nearest 
point  on  the  staff,  the  bulb  would  be  involved  to  an  un- 
necessary extent.)  As  soon  as  the  point  of  the  knife  has 
entered  the  groove,  it  is  pushed  along  for  half  an  inch, 
dividing  the  floor  of  the  urethra  to  that  extent,  and  then 


Fig.  282. 


Lateral  lithotomy.     Ilelatious  of  the  two  iucisions  to  eacli  other  and  to  the  prostat*. 

(Thompson.) 

withdrawn,  cutting  steadily  downward  and  outward  so  as  to 
make  a  cutaneous  incision  about  three  inches  long,  passino" 
midway  between  the  anus  and  left  tuber  ischii. 

The  probe-pointed  Blizard's  knife,  guided  upon  the  left 
index-finger,  is  passed  into  the  groove,  jnid  the  surgeon  takes 
the  handle  of  the  stafi'  from  the  assistant,  depresses  it  some- 
what, and  pushes  the  knife  along  until  its  point  is  arrested  at 
the  termination  of  the  groove  at  the  end  of  the  staff.     Then 


LATERAL    LITHOTOMY.  441 

depressing  tlic  liaiidlc  of  tlie  knife,  and  bearing  in  mind 
the  sbape  and  position  of  tlie  pro.state,  lie  makes  an  incision 
in  it  d(>\\nward  and  outward  at  an  angle  of  about  -JO'^  witli 
the  horizon  (Fig.  2H2). 

The  index-finger  is  next  intnxbiced,  the  staff"  withdrawn, 
and  the  neck  of  the  bhidder  gently  dilated  with  the  finger, 
or,  if  the  perineum  is  deep  and  fat,  with  the  blunt  gorget 
carried  in  along  the  groove  in  the  staff.  If  the  stone  is 
more  than  an  inch  in  diameter,  the  Blizard's  knife  must  be 
reintroduced,  and  the  prostate  cut  upon  its  right  side  also. 

The  forceps  are  then  introduced  as  the  finger  is  with- 
drawn, and  the  stone  sought  for  by  opening  and  closing  the 
blades  at  different  points  on  the  floor  of  the  bladder ;  or  the 
small  end  of  the  scoop  may  be  introduced,  placed  in  contact 
with  the  stone,  and  the  forceps  guided  along  it.  If  the  stone 
is  seized  in  a  faulty  direction,  it  must  be  dropped  and  caught 
again,  or  strai^-htened  Avith  the  fino;ers  wdiile  still  held  be- 
tween  the  blades.  Extraction  should  be  made  slowly  down- 
ward and  outward  in  the  line  of  the  external  incision,  and 
aided  by  lateral  movements  of  the  handles.  The  old  rule 
was  that  the  force  used  should  be  two-thirds  lateral,  one- 
third  extractive.  If  it  is  found  that  the  stone  is  too  large 
to  be  removed  w^ithout  employing  too  much  force,  it  must  be 
crushed,  and  the  fragments  removed  separately.  Small 
stones  and  fragments  are  best  removed  with  the  scoop  and 
by  thorough  washing. 

In  operating  upon  children  certain  modifications  are  re- 
quired. The  prostate  being  very  small  the  incision  usually 
passes  quite  beyond  its  limits,  but  this  is  a  matter  of  slight 
importance  since  the  ill  results  which  follow^  in  adults  and 
old  men  do  not  occur  at  this  ao;e.  If  the  incision  in  the 
urethra  and  at  the  neck  of  the  bladder  is  not  sufficiently 
free,  it  may  happen  that,  in  the  attempt  to  introduce  the 
finger,  the  urethra  will  be  torn  entirely  across  and  the  blad- 
der pushed  up  before  it.  Again,  the  bladder  is  placed 
higher  in  the  child  than  it  is  in  the  adult,  and  therefore 
the  point  of  the  knife  must  be  more  raised  in  making  the 
deep  incision,  and  care  must  be  taken  not  to  let  it  slip 
in  between  the  rectum  and  bladder.     ^Ir.  Erichsen^  says  he 

^  Science  and  Art  of  Surgery,  vol.  ii.  p.  082,  Phila.,  1873. 


442      OPERATIONS    OX   GEXIT  0-U  RIN  A  R  Y   ORGANS. 

has  known  this  to  occur  in  several  instances,  and  the  forceps 

to  be  passed  into  this  space  under  the  impression  that  it  was 
the  hhidder. 

It  has  also  happened  to  some  surgeons  to  force  the  beak 
of  the  staff  through  the  roof  of  the  urethra  into  the  space 
between  the  bladder  and  posterior  face  of  the  pubes,  and  to 
be  so  deceived  by  its  freedom  of  motion  in  the  loose  cellular 
tissue  of  that  region  that  they  thought  it  was  in  the  bladder, 
and  cut  upon  it  accordingly. 


Fig.  283. 


Fig.  284 


Fig.  285. 


Staff  for  median  lithotumv. 


Ball-iX)inted  director.         Double-edged  scalpel. 


Median  Litliotomy. — The  only  instruments  required  other 
than  those  used  in  the  lateral  operation  are  a  staff,  director, 


LATERAL    LITHOTOMY. 


448 


and  knife.  The  staft'  has  a  central,  broad,  deep  groove  on 
its  convexity  (Fig.  283),  tlie  director  has  a  ball-point  (Fig. 
284),  and  the  knife  is  straight,  stout,  and  sharp  pointed, 
with  a  cutting  edge  u[)on  the  back  also  for  a  short  distance 
from  the  point  (Fig.  285). 

The  patient  having  been  bound  in  the  lithotomy  position 
and  the  staft'  introduced,  the  surgeon  places  his  left  index 
finger  in  the  rectum  against  the  apex  of  the  prostate,  and 
plunges  the  knife  with  its  edge  upward  into  the  raphe  of 
the  perineum  half  an  inch  in  front  of  the  anus  in  such  a 
direction  that  its  point  will  enter  the  groove  of  the  staff  just 
at  the  apex  of  the  prostate.  The  knife  is  pushed  very 
slightly  back  along  the  groove  so  as  certainly  to  open  the 
urethra  and  nick  the  end  of  the  j^rostate,  then  brought  for- 
ward, dividing  the  membranous  portion  of  the  urethra,  and 
swept  around  the  bulb  by  raising  the  handle,  making  an 


Median  lithotomy  with  rectangular  staff". 

external  incision  upward  along  the  raphe  for  about  one  and 
a  quarter  inches.  The  director  is  next  passed  along  the 
staff  into  the  bladder,  the  two  separated  angularly  to  make 
partial  dilatation  of  the  neck,  the  staff  withdrawn,  and  the 
dilatation  completed  with  the  finger.  The  forceps  are  then 
introduced  and  the  stone  removed  as  in  lateral  lithotomy. 

Sir  Henry  Thompson  makes  the  incision  from  without 
inward,  and  Mr.  Erichsen  uses  a  rectangular  staff  (Fig. 
286),  placing  its  angle  close  against  the  apex  of  the  prostate. 


444      OPERATIONS  OX   GENITO  -  U  RIN  A  R  Y  ORGANS. 


Fig.  287. 


Bilateral  Lithotomy  (Dupuytren). —  The  characteristic 
of  this  operation  is  the  bilateral  incision  of  the  prostate, 
accomplished  by  means  of  Dupuytren's  double 
lithotome  cache  (Fig.  287).  The  preliminary 
part  of  the  operation,  including  the  incision 
into  the  urethra,  may  be  the  same  as  in  median 
lithotomy,  but  the  advantage  of  less  risk  of 
hemorrhage  which  this  presents  is  more  than 
offset  by  the  lack  of  correspondence  in  form 
and  direction  between  the  incision  in  the  pros- 
tate and  that  in  the  perineum,  and  the  greater 
risk  of  infiltration  of  urine  which  this  involves. 
The  double  lithotome  cache  is  an  instrument 
composed  of  a  flattened,  slightly  curved,  me- 
tallic sheath,  blunt-pointed,  and  mounted  on  a 
stout  handle.  Within  this  sheath  are  two 
blades  of  the  same  shape  and  sharp  on  their 
concave  borders,  which  can  be  made  to  pro- 
ject, one  on  each  side,  as  shown  in  Fig.  287, 
by  pressing  upon  a  lever  in  the  handle ;  the 
degree  of  projection  is  regulated  at  will  by  a 
screw. 

The  patient  is  placed  in  the  lithotomy  posi- 
tion, the  stafi:'  introduced  and  held  as  before 
described.  The  suro-eon  draws  the  skin  of 
the  perineum  tight  with  his  left  hand,  and 
makes  a  curved  incision  beginning  midway 
between  the  anus  and  the  right  tuber  iscliii, 
passing  half  an  inch  in  front  of  the  anus,  and 
terminating  on  the  left  at  a  point  correspond- 
ini:  to  that  at  which  it  beo;an.  The  skin,  sub- 
cutaneous  tissue,  and  anterior  fibres  of  the 
sphincter  ani  are  divided  along  the  line  of  the 
incision,  and  the  bulb  drawn  forward  if  en- 
countered ;  the  left  index-finirer  is  then  intro- 
duced  into  the  wound,  the  groove  in  the  staff' 
found,  and  the  membranous  portion  of  the  urethra  divided 
f  >r  a  distance  of  about  half  an  inch  from  behind  forward. 
The  lithotome  is  next  introduced  closed,  its  concavity  up- 
ward, and  its  point  engaged  in  the  groove  and  passed  along 
the  bladder.     The  staft"  is   then   withdrawn,  the  lithotome 


Diipuytieu's 
double  litbo- 
tonie  cache. 


PRERECTAL    LITHOTOMY.  445 

reversed  so  as  to  turn  its  concavity  downward,  its  blades 
opened  to  tlie  full  extent  previously  determined  ui)on,  and 
the  instrument  slowly  withdrawn.  This  part  of  the  opera- 
tion must  be  conducted  with  great  care ;  the  surgeon  grasps 
the  lithotome  with  both  hands,  holds  it  steadily  in  the  me- 
dian line,  and  depresses  the  handle  gradually  as  the  instru- 
ment comes  out.  As  soon  as  the  resistance  is  felt  to  have 
been  overcome  he  closes  the  blades  and  withdraws  the 
lithotome  entirely.  The  forceps  are  then  introduced  and 
the  stone  removed  as  before. 

Pre-rectal  LitJiotomy  (Nelaton). — The  bilateral  opera- 
tion gives  a  large  opening,  but  exposes  to  the  risk  of  cutting 
into  the  rectum  or  into  the  bulb  ;  Nelaton,  therefore,  modi- 
fied the  first  stage  w^ith  a  view  to  diminishing  these  risks, 
giving  to  his  modification  the  name  of  pre-rectal  lithotomy. 
The  instruments  used  are  the  same  as  in  the  bilateral 
operation. 

The  patient  is  placed  in  the  lithotomy  position  and  the 
staff  introduced.  The  surgeon  passes  his  left  index-finger 
into  the  rectum  and  places  it  against  the  apex  of  the  pros- 
tate. Then,  steadying  the  anterior  margin  of  the  anus  w^ith 
the  thumb  of  the  same  hand,  he  makes  a  curved  incision 
beginning  tw^o  centimetres  from  the  anus  on  the  right  side, 
crossing  the  median  line  of  the  perineum  one  and  a  half 
centimetres  in  front  of  it,  and  ending  on  the  left  side  at  a 
point  corresponding  to  that  at  which  it  began.  Or,  if  it  is 
wished  to  make  it  more  precisely,  make  a  transverse  inci- 
sion three  centimetres  long,  its  centre  resting  upon  the 
median  line  one  and  a  half  centimetres  in  front  of  the  anus, 
and  then  from  each  end  of  this  line  make  one  obliquely 
downw^ard  and  outward  to  a  point  two  centimetres  from 
the  lateral  margin  of  the  anus.  The  posterior  lip  of  the 
incision  is  draw^n  down  by  the  thumb,  stretching  the  ante- 
rior fibres  of  the  sphincter,  and  thus  making  it  easier  to 
divide  them.  This  division  must  be  made  very  carefully 
layer  by  layer,  using  the  sponge  constantly,  and  if  neces- 
sary a  vertical  incision  may  be  made  through  the  skin  along 
the  raphe  to  give  more  room.  When  the  division  is  com- 
plete the  anterior  wall  of  the  rectum  can  be  easily  pressed 
downward,  and  the  membranous  portion  of  the  urethra  and 

38 


446      OPERATIOXS  ON   GEXITO  -  URIN  A  RY  ORGANS. 

the  prostate  felt  at  the  bottom  of  the  wound.  The  knife,  a 
lono;  narrow  one,  is  then  entered  with  its  back  toward  the 
rectum,  its  point  passed  into  the  groove  of  the  staff  at  the 
apex  of  the  prostate,  and  the  urethra  divided  hingitudinallj 
for  half  an  inch  from  behind  forward,  by  depressing  the 
handle  of  the  knife  and  pressing  its  point  forward  with  the 
finger  placed  against  its  back. 

The  double,  lithotome  is  then  entered  and  the  prostate 
incised  as  in  the  bilateral  operation. 

Recto-vcsical  Lithotomy. — This  operation  has  been  almost 
entirely  abandoned,  and  therefore  only  a  brief  description 
Tvill  be  given.  The  original  plan  was  to  divide  the  sphincter 
and  anterior  wall  of  the  rectum,  and  then  the  posterior  por- 
tion of  the  prostate  and  the  adjoining  wall  of  the  bladder  in 
the  median  line,  guiding  upon  the  groove  of  the  staff.  More 
recently,  however,  Theodore  Schaeffer'  has  proposed  an- 
other method.  He  dilates  the  bladder  by  injecting  air  or 
carbonic  acid  gas,  then  introduces  a  Sims's  speculum  into 
the  rectum,  pinches  up  a  transverse  fold  of  the  rectal  mu- 
cous membrane  above  the  base  of  the  prostate  with  forceps, 
transfixes  and  cuts  through  it.  He  next  divides  the  pros- 
tato-peritoneal  aponeurosis  longitudinally,  and  the  wall  of 
the  bladder  in  the  same  line  Avitli  scissors,  after  passing  the 
point  of  one  of  the  blades  through  into  the  groove  of  the 
staff  previously  introduced  into  the  bladder  through  the 
urethra. 

Supra-pubic  Lithotomy  and  Cystotomy. — This  operation 
has  of  late  come  into  greater  favor  for  the  removal  of  large 
stones  and  of  tumors  of  the  bladder,  and  a  great  improve- 
ment in  the  method  of  its  performance  has  been  made  by 
Petersen  in  the  elevation  of  the  bladder  by  the  inflation  of  a 
laro;e  rubber  baor  introduced  into  the  rectum. 

The  interior  of  the  l)ladder  is  cleaned  by  washing  with  an 
antiseptic  solution,  and  the  organ  distended  by  an  injection 
until,  if  possible,  it  rises  well  above  the  pubes.  Some  sur- 
geons make  the  injection  through  a  curved  metal  catheter 
and  tie  it  in  by  a  rubber  cord  wound  about  the  penis,  to 

^  Quoted  by  Dubrueil,  ^Medecine  Operatoire,  p.  815. 


PERINEAL    LITHOTRITY.  447 

serve  later  as  a  guide  in  opening  the  blad'ler.  Tlien  tlie 
roctal  bag,  having  a  capacity  of  about  a  pint,  is  introduced 
and  distended,  and  an  incision  made  in  tlie  median  line  close 
above  the  pubes,  and  carried  down  layer  by  layer  until  the 
bladder  is  reached.  The  distention  of  the  bladder  raises  the 
reflection  of  the  peritoneum  well  above  the  pubes,  so  that, 
with  care,  there  is  no  danger  of  its  being  divided.  Then, 
with  curved  needles,  a  stout  ligature  is  fixed  in  the  wall  of 
the  bladder  on  each  side  of  the  median  line,  and  the  wall 
divided  between  them  wiih  a  sharp-pointed  knife  from  above 
downward. 

The  proper  subsequent  treatment  is  still  in  dispute.  Some 
close  the  wound  in  the  bladder  with  sutures  passed  through 
its  wall,  but  not  through  its  mucous  membrane,  and  drain 
away  the  urine  by  a  catheter  kept  in  the  urethra.  Others, 
and  this  seems  to  me  to  be  the  more  prudent  plan,  close  the 
bladder  wound  only  in  part  and  drain  its  cavity  through 
a  lonor  rubber  tube  introduced  throuo;h  the  wound.  The 
external  wound  should,  in  either  case,  be  (partly)  closed  and 
drained. 

If  more  room  is  needed  during  the  operation  the  insertions 
of  the  muscles  on  the  pubes  on  each  side  of  the  incision  may 
be  divided. 

Perineal  Litliotrity  (Dolbeau). — By  this  operation  access 
to  the  bladder  through  the  perineum  is  obtained  by  means 
of  a  small  incision  through  the  skin  and  urethra,  together 
with  dilatation  of  the  neck  of  the  bladder,  so  that  a  litho- 
trite  can  be  introduced  of  sufficient  size  and  strength  to 
crush  the  stone  and  effect  its  removal  at  a  single  sitting. 
The  special  instruments  required  are  the  dilator^  one  of 
which  is  represented  in  Fig.  288,  and  a  strong  lithotrite,  if 
the  stone  is  too  hard  to  be  crushed  by  forceps. 

The  patient  is  placed  in  the  lithotomy  position,  and  a 
grooved  staff  introduced  and  held  vertically  in  the  median 
line.  The  suroreon,  beo;innino;  close  to  the  margin  of  the 
anus,  makes  an  incision  not  more  than  one  inch  in  length 
along  the  raphe  of  the  perineum;  he  divides  the  tissues 
layer  by  layer  until  he  reaches  the  membranous  portion  of 
the  urethra,  and  incises  it  longitudinally  for  one-quarter  of 
an  inch.     He  then  passes  the  dilator  into  the  wound,  engages 


448   OPERATIONS  OX  GEN  ITO- U  Kl  N  A  R  Y  ORGANS. 

its  point  in  the  groove  of  the  staff,  holds  it  steadily  at  right 
angles  to  the  plane  of  the  perineum,  and  dilates  it  to  the  full 
extent.     Xext,  closing  the  dilator  and  keeping  its  point  in 


Fig.  288. 


Fig.  289. 


Dolbeaus  dilator. 


Guyon-Duiilay  dilator. 


CATHETERIZATION.  449 

the  ^rr<^<^ve,  lie  depresses  the  handle  of  the  staff  4n°  oi-  ')0° 
beyond  the  vertical  line  in  which  it  has  been  held,  and  at 
the  same  time  slips  the  dilator  along  nearer  to  the  neck  of 
the  Idadder.  lie  again  dilates,  closes  the  instrument,  passes 
it  fairly  into  the  bladder,  withdraws  the  staff,  and  dilates  for 
the  third  time.  This  time  the  dilatation  must  not  be  carried 
beyond  a  diameter  of  two  centimetres,  in  order  to  avoid 
tearing  the  neck  of  the  bladder.  Finally,  the  dilator  is 
closed  and  withdrawn. 

Guyon  and  Duplay  use  the  dilator  shown  in  Fig.  289, 
introducinor  it  at  once'  into  the  bladder,  withdrawinfr  the 
Staff,  and  dilating:  bv  introducinir  successively  the  different 
centre  pieces. 

The  stone,  if  not  more  than  one  centimetre  in  diameter, 
may  be  removed  entire,  but  in  the  great  majority  of  cases 
it  should  first  be  crushed  by  means  of  strong  forceps  or  a 
lithotrite,  and  then  removed  in  fragments.  Duplay  guides 
the  forceps  upon  his  finger :  Dolbeau  insists  that  the  finger 
should  never  be  introduced,  since  it  is  large  enough  to  tear 
the  neck  of  the  bladder. 


CHAPTER  VIII. 

OPERATIONS  UPON  THE  GENITO-URINARY  ORGANS  OF  THE 

FEMALE. 

CATHETERIZATION. 

The  surgeon,  standing  on  the  right  side  of  the  patient 
and  holding  the  catheter  in  his  right  hand,  with  its  con- 
vexity lying  on  the  palmar  surface  of  the  index-finger  and 
its  beak  not  quite  reaching  to  the  end  of  the  distal  phalanx 
(Fig.  290),  separates  the  nymphne  with  the  thumb  and 
middle  finger  of  his  left  hand,  introduces  his  right  index- 
finger  at  the  fourchette  and  brings  it  forward,  recognizing 
the  entrance  to  the  vagina  and  its  anterior  border,  and  stop- 
ping when  he  feels  the  pouting  orifice  of  the  urethra.     Then 

38* 


450      OPERATIONS  ON   GENITO-URINARY  ORGANS. 

keeping  the  pulp  of  the  finger  below  and  in  contact  with 
the  orifice  he  passes  the  catheter  in. 

Fig.  290. 


Mode  of  holdino;  the  catheter. 


Unless  there  is  some  reason  to  the  contrary,  this  should 
always  be  done  without  exposure  of  the  parts. 


EXTERNAL  URETHROTOMY. 


The  Buttonhole   Operation  (Emmet)  (Fig.  291).  —  The 
patient  is  anaesthetized  and  placed  on  the  left  side,  and  the 


Fig.  291. 


LITHOTOMY. 


451 


fourclictte  R'tractcd  with  ;i  small  Sims's  spcculiiiii.  A  full- 
sized  inetal  sound  is  introduced  into  the  urethra,  then  the 
tissues  in  the  vaginal  surface  are  caught  up  with  a  tenacu- 
lum and  divided  kmgitudinally  midway  between  the  meatus 
and  the  neck  of  the  bladder.  The  incision  may  then  be 
extended  with   scissors.      Neither  the  neck  of  the  bladder 

Fiu.  202. 


nor  the  meatus  should  be  divided.  If  the  incision  is  to  be 
kept  open,  the  urethral  mucous  membrane  must  be  drawn 
out  throuo;h  it  and  stitched  with  cato-ut  to  the  edsje  of  the 
divided  vaginal  surface.  The  incision  may  be  conveniently 
made  with  Emmet's  buttonhole  scissors  (Fig.  292). 


LITHOTOMY. 


Besides  the  supra-puMc,  which  is  performed  in  the  man- 
ner already  described,  there  are  the  urethral  and  vesico- 
vaginal operations.  In  the  former  the  stone  is  removed 
through  the  urethra  after  the  calibre  of  this  canal  has  been 
increased  by  an  incision  along  its  anterior  (upper)  w^all,  or 
on  one  or  both  sides,  incisions  which  do  not  extend  into 
the  vagina.  In  the  latter  the  stone  is  removed  through  an 
incision  made  in  the  vesico-vaginal  septum. 

Urethral  Lithotomy. — The  only  instruments  actually  re- 
quired are  a  director,  a  probe-pointed  knife,  and  forceps,  but 
some  surgeons  prefer  to  make  the  incision  with  a  single  or 


452      OPERATIONS  ON  GEN  I  TO  -  U  RIN  A  R  Y   ORGANS. 

double  litliotome  introduced  alone  or  upon  a  director.  Lat- 
eral incisions  should  incline  upward  rather  than  downward ; 
conse(|uentlj,  if  the  double  lithotome  is  used,  its  concavity 
should  be  turned  toward  the  symphysis.  The  extraction  of 
the  stone  requires  no  additional  description. 

Vesieo-vaginal  LitJiotoinij. — The  patient  may  be  placed 
in  the  usual  lithotomy  position,  or  upon  the  side,  or  upon 
the  face.     A  Sims's  speculum  (Fig.  293)  is  pressed  against 


Fig.  293. 


Sims's  speculum. 

the  posterior  wall  of  the  vagina,  and  a  grooved  catheter  in- 
troduced into  the  bladder  and  confided  to  an  assistant,  who 
keeps  it  pressed  well  against  the  vesieo-vaginal  septum. 

Guiding  his  knife  upon  the  groove  the  surgeon  makes  an 
antero-posterior  incision  in  the  median  line  of  the  anterior 
wall  of  the  vagina,  about  one  inch  in  length,  and  not  in- 
volving the  neck  of  the  bladder,  passes  in  his  index-finger, 
and  then  the  forceps  upon  the  finger  as  a  guide. 

Emmet  places  no  sutures,  but  allows  the  wound  to  close 
spontaneously,  keeping  the  bladder  clean  by  frequent  wash- 
ings.    Guyon  closes  the  incision  immediately  with  sutures. 

In  a  recent  discussion  in  the  Societe  de  Chirurgie^  the 
fact  was  brought  out  that  lithotomy  and  lithotrity  upon  the 
female  are  more  dangerous  operations  than  they  are  usually 
said  to  be.  The  fatal  complications  are  of  two  kinds  :  peri- 
tonitis in  patients  who  have  previously  been  affected  by  it; 
and  pyaemia,  originating  in   inflammation  of  the  spongio- 

1  Bull,  de  la  Societe  de  Chirurgie,  1877,  pp.  182  and  400. 


OCCLUSION,  OR    ATRESIJ^]    VAGINt!^:.  453 

vascular  tissuo  constitiitiiiir  part  of  tlic  vesica »- vaginal  sc))- 
tuiii.  Speaking  generally,  it  may  be  said  that  lithutrity'  is 
more  dangerous  in  the  female  than  lithotomy,  that  tlie 
supra-})ubie  operation  should  be  used  for  large  calculi,  dila- 
tati(m  of  the  urethra  for  small  ones,  and,  Avitli  crushing,  for 
large  friable  ones  Avhen  the  inflammation  is  not  hio-h  and 
there  has  been  no  previous  peritonitis ;  urethral  or  vesico- 
vaginal lithotomy  in  other  cases.  As  to  the  com})arative 
merits  of  urethral  and  vesico-vaginal  lithotomy  opinions  are 
divided ;  the  former  is  followed  occasionally  by  permanent 
incontinence,  the  latter  'by  fistula ;  probably,  too,  the  latter 
is  somewhat  more  dangerous  than  the  former. 


OCCLUSION,  OR  ATRESIA    VAGIX^. 

When  the  occlusion  is  due  simply  to  an  imperforate  hy- 
men it  may  be  relieved  by  successive  punctures  with  a  small 
trocar  or  asi)irator,  and  when  all  the  accumulated  menstrual 
blood  has  been  thus  removed,  and  the  cavity  well  washed 
out  with  a  two  or  three  per  cent,  solution  of  carbolic  acid, 
the  hymen  may  be  excised,  or  a  large  puncture  made,  and 
kept  open  by  frequently  passing  a  sound.  It  must  be  re- 
membered that  very  serious  complications,  such  as  peri- 
tonitis and  septic  poisoning,  may  follow  this  simple  operation 
when  there  has  been  a  large  accumulation  of  menstrual 
blood  above  the  obstruction. 

When,  on  the  other  hand,  the  occlusion  is  due  to  incom- 
plete development  of  the  vagina,  a  more  systematic  opera- 
tion is  required.  The  surgeon  first  assures  himself  by 
dio-ital  examination  throuo-h  the  rectum  of  the  existence  of 
the  uterus,  then  places  the  patient  upon  her  back  with  her 
thighs  flexed  and  abducted,  and  introduces  a  sound  into  the 
bladder  and  confides  it  to  an  assistant,  lie  next  passes  his 
left  index-finger  into  the  rectum,  makes  a  transverse  inci- 
sion across  the  centre  of  the  obliteration,  and  carries  it  in 
the  direction  of  the  uterus  by  successive  short  cuts  with  the 
knife,  or  by  tearing  with  a  director  or  his  fingers,  guiding 

^  In  this  remark  reference  is  made  to  the  old  operation  of  lithotrity. 
The  few  cases  of  litholapaxy  in  the  female  of  which  I  have  knowledge 
have  been  successful. 


454      OPERATIONS   OX   GENITO- U  RIN  A  R  Y  ORGANS. 

his  cour^'e  by  the  sound  in  the  bhidder  and  the  finger  in  the 
rectum.  As  soon  as  fluctuation  can  be  felt  in  front  of  the 
uterus  he  punctures  with  a  trocar  and  enlarges  the  puncture 
with  a  probe-pointed  bistoury. 


PEKINEORAPHY. 

Dr.  Emmet^  has  recently  shown  that  the  lesion  heretofore 
known  as  "partial  rupture  of  the  perineum,"  and  supposed 
to  be  a  laceration  along  the  posterior  median  line  of  the  tis- 
sues at  the  lower  part  of  the  vagina  and  the  perineum,  is 
actually  a  transverse  rent  at  or  within  the  ostium  vaginae, 
which,  by  the  dropping  and  eversion  of  the  lower  lip  of  the 
wound,  is  made  to  present  the  appearance  of  a  longitudinal 
one.  He  has  also  recently  recognized  and  described  a 
variety  of  this  lesion  in  which  the  laceration  is  submucous, 
in  which  the  muscular  and  fascial  diaphragm,  constituted  in 
part  by  the  sphincters  and  closing  the  outlet  of  the  pelvis,  is 
torn  away  from  the  supporting  fasciae  and  muscles  which 
run  upward  to  attach  its  centre  to  the  inner  side  of  the  bony 
pelvis,  and,  having  thus  lost  its  support,  allows  the  posterior 
part  of  the  vulva  to  be  everted,  with  production  of  a  recto- 
cele  by  protrusion  of  the  rectum  through  the  (subcutaneous) 
gap.  To  this  latter  condition  he  gives  the  name  prolapse 
of  the  jjosterior  wall  of  the  vagina.  The  two  conditions,  the 
subcutaneous  and  the  complete  rents,  are  essentially  the 
same,  and  require  nearly  the  same  denudation  of  the  sur- 
face. The  aim  of  the  operator  in  either  case  is  to  lift  up  the 
depressed  and  everted  lower  lip,  unite  its  edge  to  that  of  the 
mucous  membrane  of  the  vaa:ina  at  the  crest  of  the  rectocele, 
and  thus  cover  in  the  latter  and  renew  its  anterior  support. 

Laceration  of  the  vulvar  orifice  in  the  posterior  median 
line  may  occur  without  coexistence  of  the  above  described 
lesion,  bes-inninir  at  the  fourchette  and  extendino-  backward, 
but  such  laceration  is  unimportant  because  it  involves  only 
parts  that  lie  outside  the  real  support  of  the  viscera. 

A  third  form  is  the  important  one  in  Avhich  laceration  of 
the  sphincter  ani  in  the  median  line  takes  place.     In  non- 

^  Principles  and  Practice  of  Gynecology,  1884,  p.  364. 


PERIXEOKAPIiy 


4r)r, 


instrumental  delivery  this  begins  as  a  longitmlinal  slit  in  tlic 
recto-vaixinal  septum  and  extends  from  within  outward  and 
forward.  When  caused  bv  tlio  forceps  it  begins  at  the  four- 
chette  and  extends  backward.  To  this  form  Dr.  Emmet 
limits  the  term  rupture  of  the  perineum. 

Accepting  this  classification,  I  shall  describe  tlie  operation 
for,  1st,  Prohipse  of  the  posterior  wall  of  the  vagina, — two 
varieties,  with  and  without  laceration  of  the  mucous  mem- 
brane of  the  vagina  :  and,  2d,  Rupture  of  the  Perineum 
(and  the  sphincter  ani). 


Fig.  294. 


Fig.  295. 


Fig.  296. 


Fig.  29" 


Fig.  294.  Curved  scissors.    Fig.  295.  Emmet's  scissors.      Fig.  296.  Thoma^j's  toothed 
forceps.    Fig.  297.  Sponge-holder. 

Prolapse  of  the  Posterior  Wall  of  the  Vagina.  (1st 
variety,  without  surflice  laceration.)  Operation. — Thighs 
flexed  on  abdomen  and  supported  under  the  arm  of  an 
assistant  on  each  side,  who  also  draw  aside  the  labia  and 
hold  the  tenacula  during  the  act  of  denudation.  The  ope- 
rator seizes  with  a  tenaculum  the  mucous  membrane  of  the 
vagina  at  the  crest  of  the  rectocele  in  the  median  line  at  a 
point  which  can  be  drawn  down  to  the  urethral  orifice  by 
gentle  traction,  and,  having  thus  drawn  it  down,  has  it  held 


456      OPERATIONS   ON   GENITO-U  RIN  AR  Y  ORGANS 


in  place  by  the  assistant.  Then,  ^ith  two  other  tenacula, 
he  hooks  up  the  lowest  caruncle,  or  vestige  of  the  hymen, 
on  each  side,  and  draws  them  upward  and  outward  to  the 
first  tenaculum.  This  movement  creates  an  inverted,  cres- 
centic,  transverse  fold  within  the  vagina  just  below  the  first 
tenaculum,  its  horns  shading  gradually  into  the  sulcus  on 
each  side,  and  a  shallow  longitudinal  fold  in  the  median  line 
between  the  last  two  tenacula.  The  opposed  surfaces  of 
these  folds  constitute  the  area  to  be  denuded. 

Dropping  one  lateral  tenaculum,  he  gives  the  other  to  an 
assistant  who  draws  it  gently  outward  to  define  by  this  trac- 
tion the  limits  of  the  denudation  on  that  side,  and  then  the 
surgeon  denudes  by  catching  up  the  mucous  membrane  with 
a  hook  or  pronged  forceps  and  removing  it  with  scissors  in 
successive  strips.  The  process  is  then  repeated  on  the  oppo- 
site side.  Care  must  be  taken  not  to  denude  too  high  on 
the  posterior  wall. 

Silver  sutures  are  tlien  passed  to  unite  the  parts  in  the 
positions  given  them  by  the  first  approximation  of  the  three 
tenacula,  producing  the  line  of  union  indicated  in  Fig.  298. 

Fig.  298. 


Diagram  sliowiuf;  the  line  of  uniou  and  direction  of  the  sutures. 

The  sutures  of  the  crescentic  part  should  be  of  silver  wire ; 
those  of  the  central  line  may  be  of  silver,  silk,  or  catgut.  A 
final  silver  suture  should  be  passed  through  the  labium  near 
the  caruncle  on  one  side,  across  to  the  posterior  wall  of  the 
vagina,  under  its  mucous  membrane  for  nearly  an  inch  just 
above  the  edore  of  the  denudation,  and  then  through  the 
other  labium  at  a  point  opposite  to  that  at  which  it  began. 
In  passing  the  sutures  a  thick,  straight,  sewing  needle 


PERINEORAPHY.  457 

armed  with  silk  should  be  used,  and  the  tissues  to  be  tra- 
versed l)y  it  should  be  pressed  f(jrward  by  the  finger  in  the 
rectum.  The  sutures  should  not  be  buried  throughout  their 
course,  but  should  cross  the  fold  midway  between  its  free 
edjxe  and  its  bottom.  The  silver  wire  is  drawn  throu<ih  in 
the  loop  of  the  silk.  The  appearance,  when  the  operation 
is  completed,  is  shown  in  Fig.  299,  the  crescentic  part 
being  hidden  within  the  vacrina. 

Fig.  299. 


Appearance  at  completion  of  the  operation. 

2d  Variety.  Prolapse  vnih  Surface  Laceration. — The 
position  of  the  patient  is  the  same  as  in  the  preceding  form, 
and  the  area  of  denudation  is  determined  in  like  manner ; 
speaking  generally,  it  must  extend  downward  to  the  line  of 
junction  between  the  skin  and  the  cicatricial  mucous  mem- 
brane. Its  shape,  when  spread  out,  is  that  of  a  trefoil 
(Fig.  300).  The  sutures  are  passed  in  order  from  below 
upward,  and  none  tightened  till  all  are  in  place.  The  lower 
ones  are  buried  throughout  their  course ;  the  upper  ones  are 
partly  exposed  on  each  side,  as  shown  in  Fig.  301.  The 
suture  marked  D  includes  about  an  inch  of  the  recto-vaginal 
septum :  the  uppermost  suture,  (7,  passes  through  the  mu- 
cous membrane  of  the  septum  above  the  denudation,  and 
when  tightened  di'aws  it  down  like  a  hood  to  protect  the 

39 


458      OPERATIONS   ON   G  ENITO-U  RI N  A  R  Y   ORGANS. 

approximated  edges,  and  also  sustains  all  the  traction  while 
the  opposed  denuded  surfaces  are  unitinor. 


Diagram  showing  area  of  denudation.     The  parts  bearing  corresponding  figures  are 
brought  into  apposition  by  the  sutures. 

Dr.  Emmet  leaves  the  sutures  in   place  for  about  three 
weeks. 

Fig.  301. 


/  I  K 


Emmet's  operation  for  diminishing  the  vaginal  outlet  by  external  sutures. 

Laceration  of  the  Perineum,   including   the  Sphincter 
Ani. — If  the   anterior  wall  of  the  rectum  is   ruptured  for 


RUPTURED    PERINEUM. 


459 


more  than  one  or  one  and  a  lialf  inches  above  the  upper 
niar<2;in  of  the  spliincter,  Dr.  Thomas  prefers  to  close  it  by  a 
preliminary  operation,  leaving  the  restoration  of  the  peri- 
neum for  a  subsequent  one.  Dr.  T.  Addis  Emmet  was  the 
first  to  show  why  it  is  not  sufficient  simply  to  close  the  gap 
between  the  vagina  and  rectum,  and  to  demonstrate  the  need 
of  bringing  the  ends  of  the  severed  sphincter  into  close  con- 
tact with  each  other,  and  with  the  end  of  the  recto-vaginal 
septum. 

Let  Fig.  302  represejit   the  perfect  sphincter,  and  Fig. 
303  the  sphincter  ruptured  and  spread  out  with  the  points 


Fio.  302 


Fig.  304. 


Fio.  305. 


of  entrance  and  exit  of  needle  A  A,  the  dotted  line  showing 
the  course  of  the  suture,  including  the  end  of  the  recto- 
vaginal wall  0.  As  the  suture  is  twisted,  the  three*  points 
are  brought  nearer  together,  as  in  Fig.  304,  until  they 
finally  unite,  as  in  Fig.  305.  If  the  first  needle  is  passed 
in  and  out  at  BB,  complete  union  of  the  ends  of  the  muscle 
will  not  be  obtained,  and  loss  of  function  will  persist.  The 
first  suture  is  the  important  one,  and  must  bring  the  torn 


460      OPERATIONS   ON  GENITO- U  R  IN  A  R  Y   ORGANS. 

ends  of  the  muscle  into  contact  with  each  other  and  with  the 
end  of  the  septum. 

In  freshening  the  parts  before  passing  the  needles,  the 
two  lateral  triangles,  forming  the  ruptured  surface  of  the 
body  of  the  perineum,  are  denuded,  and  the  line  of  denuda- 
tion is  prolonged  backward  along  the  edge  of  the  recto- vaginal 
septum.  This  denudation  must  extend  along  the  edge  of 
the  mucous  membrane  of  the  rectum,  but  not  include  it. 
Fig.  306  is  a  schematic  representation  of  the  end  of  the 


Fig.  306. 


Fig.  307. 


Kuptured  sphincter.     First  sutiire. 


Cuuiplete  perineal  rupture.     J'irst  and 
second  sutures  in  iiluce. 


ruptured   bowel,   the  points  of  entrance  and  emergence  of 
the  needle,  and  the  course  of  the  first  suture. 

The  rule  for  passing  the  first  suture,  then,  is,  to  enter  the 
needle  as  low^  down  as  the  lower  edge  of  the  anus,  pass  it 
thence  upward  through  the  recto-vaginal  septum,  completely 


11  U  I'T  U  K  E  I)    PERINEUM. 


461 


encirclin«5  the  rent,  and  bring  it  out  alongside  the  lower  edge 
of  the  anus  on  the  otlier  side.  Its  action,  tlien,  is  like  that 
of  a  purse  string,  it  puckers  u})  the  open  parts,  controls  the 
action  of  the  sphincter,  and  guards  against  the  two  principal 
sources  of  failure,  recto-vaginal  fistula  and  non-union  of  the 
sphincter  (Fig.  307). 

Dr.  Emmet  now  recommends  that  this  injury  should  be 
treated  as  if  it  were  "  a  recto-vaginal  fistula  in  the  median 
line,  with  the  sides  easily  approximated."  (Loc.  cit.,  p.  401.) 

Fig.  ^508. 


R.\\% 


-.--:r.t.^kgsssssssssss^ 


Half  section  through  the  pubes. 


.r^S^S^^^^^^"^ 


The  denndation  is  done  with  scissors,  beginning  at  the 
outlet  and  near  the  rectal  surface,  and  continuing  from  below 
upward,  so  as  to  avoid  the  flow  of  blood  over  the  surface  yet 
to  be  freshened.  Since  the  sides  of  the  tear,  after  retrac- 
tion, are  not  sufiiciently  broad  to  give  a  good  surface  for 
union,  a  portion  of  the  adjoining  vaginal  mucous  membrane 
must  be  removed,  and  the  angle  must  also  be  extended  on 
the  vaginal  surface  for  half  an  inch  or  more  beyond  the 

39* 


462      OPERATIONS   ON   GEIsMTO-U  RIN  AR  Y  ORGANS. 

rectal  edfje.  Then,  beo;inninfr  at  the  ande,  several  trans- 
verse,  interrupted  silver  sutures  are  passed  from  the  vaginal 
edge  on  one  side,  under  the  denuded  surface,  across  the  gap, 
and  under  the  opposite  d-enuded  surface  to  the  opposite 
vaginal  edge,  and  two  or  three  additional  sutures  are  passed 
bv  the  old  method,  that  is,  befrinnino;  in  the  skin  near  the 
lower  edge  of  the  anus,  continuing  up  through  the  tissues 
alongside  the  rent,  through  the  septum,  and  down  on  the 
other  side,  so  as  completely  to  include  the  rent.  Fig.  308 
shows  these  different  sutures.  The  last  two  mentioned  are 
the  2d  and  4th  in  the  figure,  counting  from  below  upward. 


VESICO-YAGINAL  FISTULA. 

The  patient  is  prepared  for  the  operation  by  measures 
directed  to  the  improvement  of  her  general  condition,  by 
regularly  syringing  the  vagina  Avith  Avarm  water,  and  by 
dividing  any  cicatricial  bands  that  may  have  formed  in  it. 

Position. — Dr.  Thomas  recommends  the  position  known 
as  Sims's.  The  patient  is  placed  upon  the  left  side,  with 
the  thighs  flexed,  the  right  rather  more  so  than  the  left,  the 
left  arm  is  drawn  behind  her  back,  and  her  chest  brought 
flat  down  upon  the  table.  Others  prefer  the  knee-elbow 
position,  and  Simon  placed  the  patient  flat  upon  her  back, 
raised  the  hips,  and  flexed  the  thighs  as  far  as  possible  upon 
the  abdomen. 

If  the  first  position  is  employed,  an  assistant  stands  be- 
hind the  patient,  draws  the  posterior  wall  of  the  vagina  back 


Fig.  309. 


a 


o  o 

a.  Vesical  surface,     h.  Vaginal  surface,     cc.  Line  of  pai'ing. 

by  means  of  a  broad  Sims's  speculum  held  in  his  right  hand, 
while  with  his  left  he  raises  the  right  side  of  the  nates. 

The  surgeon  then  pinches  up,  with  toothed  forceps  or  a 
tenaculum,  the  vaginal  edge  of  the  fistula  at  the  point  most 
difficult  of  access,  and  cuts  off"  a  piece  including  in  breadth 


VESICO-VAGINAL    FISTULA. 


463 


all  between  the  vesical  edge  of  the  fistula  and  a  point  in  the 
vaji-ina  at  least  one-third  of  an  inch  from  the  viiirinal  edije 
of  the  fistula.     The  cutting  may  be  done  with,  curved  scissors 


Fig.  310. 


Drawing  clown  the  uterus  to  facilitate  the  paring. 

or  a  narrow-bladed  knife.  Successive  portions  of  the  edge 
are  raised  and  removed  in  like  manner,  until  the  denudation 
is  complete,  the  resulting  raw  surface  being  funnel-shaped. 


464      OPERATIONS   ON   GENITO-U  R 1 N  A  K  Y   ORGANS. 

with  its  narrowest  part  at  the  edge  of  the  vesical  mucous 
membrane,  the  membrane  itself  not  being  included  in  it 
(Fig.  309).  Or  the  point  of  the  knife  may  be  entered  into 
the  mucous  membrane  of  the  vagina  one-third  of  an  inch 


Tig,  311. 


Fig.  312. 


a     ^ 


a.  Vesical  surface      h.  Vaginal  surface,     c.  Needle. 


a- 


Fig.  313. 


Needle  holder. 


Passing  the  needle. 


from  the  edge  of  the  fistula,  brought  out  at  the  vesical 
border,  and  then  carried  right  and  left  around  the  opening 
so  as  to  cut  off  a  complete  ring  of  tissue. 

If  the  anterior    wall   of  the  vagina    is  freely  movable, 


VESICO- VAGINAL    FISTULA 


465 


Simon  brings  the  fistula  into  plain  view  by  passing  a  stout 
lifijature  throuirh  the  cervix  of  tlie  uterus,  and  drawinir  it 
down  toward  the  vulva  (Fig.  -310).  He  also  pares  the  edges 
of  the  fistula  very  freely,  and  does  not  hesitate  to  include 
the  mucous  membrane  of  the  bladder  in  the  incision. 

As  soon  as  the  hemorrhage  has  ceased,  the  sutures  may 
be  passed.  The  needle,  three-<|uarters  of  an  inch  long, 
round,  slightly  curved,  and  armed  with  a  fine  double  silk 
suture,  is  fixed  .in  a  needle  holder  (Fig.  -311).  and  entered 
at  the  angle  of  the  wound  which  is  most  difficult  of  access, 


Fios.  314,  31.3,  316. 


Fig.  317. 


A 


1 


^-MIIW^ 


half  an  inch  fi-om  the  edge  of  the  raw  surface,  and  its  point 
brought  out  at  the  edge  of  the  vesical  mucous  membrane,  but 
not  including  it  (Fig.  312),  and  there  fixed  with  a  blunt 
hook  (Fig.  316),  until  it  can  be  seized  and  drawn  through 
with  the  needle  forceps.  It  is  then  entered  at  the  corre- 
sponding point  on  the  opposite  side,  and  brought  out  on  the 
vaginal  surface  half  an  inch  from  the  edge  of  the  opening 


466      OPERATIONS   ON   GE  NITO  -  U  KIN  A  R  Y   ORGANS. 

(Fig.  313).  The  ends  of  the  ligature  are  given  into  the 
charge  of  the  assistant  who  holds  the  speculum,  and  another 
needle  is  passed  in  the  same  manner  at  the  distance  of  one- 


Fio.  818. 


Simon's  method  of  placiiit?  tlio  sutures. 


sixth  of  an  inch  from  the  first :  and  so  on,  until  a  sufficient 
number  have  heen  passed.  During  the  passing  of  the  nee- 
dles the  sides  of  the  fistula  are  fixed  by  the  tenaculum. 


V  ESI  CO  -  V  A  G  1  N  A  L    F I  ST  U  L  A 


4«J7 


When  the  notMllc  is  seized  with  foreeps  and  pulled  through, 
counter-pressure  must  he  made  upon  the  tissues,  and  this  is 
best  done  by  means  of  the  split  rod  or  fork,  represented  in 
Fig.  315,  its  prongs  passing  on  either  side  of  the  needle. 

After  all  the  ligatures  have  been  passed,  a  silver  wire, 
about  twelve  inches  long,  is  fastene<l  to  the  loop  of  the  first 
ligature  (Fig.  817,  C),  and  <lrawn  through  with  the  help  of 
the  fork.  The  silk  is  eut  off,  the  ends  of  the  wire  drawn  aside 
out  of  the  way,  and  the  others  passed  in  the  same  manner. 

Simon  used  fine  silk  sutures  (two  rows  when  the  fistula 
was  large),  tied  in  the  ordinary  manner,  and  often  passing 
through  the  vesical  mucous  membrane  (Fig.  81S). 

The  ends  of  the  silver  sutures  beinor  drawn  together,  and 
the  edges  of  the  wound  carefully  approximated,  each  thread 
is  slightly  twisted  so  as  to  keep  the  parts  in  apposition,  and 
then  the  ends  of  the  first  are  seized  with  forceps  and  twisted 
with  the  help  of  the  shield  (Fig.  314),  as  shown  in  Fig.  317 ; 
care  beinor  taken  not  to  twist  so  tiorhtlv  as  to  strantrulate  the 
tissues  engaged  in  the  loop.  The  other  sutures  are  then 
twisted  in  the  same  manner,  and  the  ends  of  each  cut  oft' 
about  half  an  inch  from  the  surface  (Fig.  319). 


r  2 


Fig.  310. 


VMvV. 


The  bladder  is  then  syrinired  to  remove  any  blood  that 
may  have  collected  in  it,  and  a  Sims's  catheter  (Fig.  320) 
passed  into  it  and  left  there. 

Fig.  320. 


Siins'3  catheter. 


The  sutures  may  be  removed  during  the  second  week. 


468      OPERATIONS   ON   GENITO-U  RIN  A  R  Y  ORGANS. 


Creation  of  a  Vesico-  Vaginal  Fistula. — This  operation 
is  sometimes  required  in  the  treatment  of  chronic  cystitis. 
Dr.  Emmet^  performs  it  as  follows :  Anaesthesia ;  Sims's 
position.     A  Sims's  speculum  is  introduced  into  the  vagina, 

Fig.  321. 


Obliteration  of  the  vagina. 

and  a  director,  abruptly  curved  an  inch  and  a  half  from  its 
extremity,  introduced  through  the  urethra.  While  the 
director  is  held  by  an  assistant  with  its  point  firmly  pressing 

'  Chronic  Cystitis  in  the  Female,  American  Practitioner,  Feb.  1872, 

and  Vesico-Vaginal  Fistula,  p.  43. 


ELYTRORAPflY,  OR   NARROWING   OF    VAGINA.     409 

in  the  median  line  against  tlie  base  of  tlie  ])lad(ler  a  little 
behind  the  neck,  tlie  surgeon  seizes  the  i)rojecting  tissue  on 
the  vaginal  surface  with  a  tenaculum,  and  exposes  the  beak 
of  the  director  by  cutting  upon  it  with  a  pair  of  scissors. 
One  of  the  blades  of  the  scissors  is  then  passed  through  the 
opening  and  a  cut  made  backward  in  the  median  line. 

If  tlie  0})ening  tends  to  close  spontaneous!}^  too  soon,  a 
hollow  glass  stud  made  of  half-inch  tubing  should  be  but- 
toned into  it.  The  vesical  rim  of  this  stud  need  not  be  more 
than  a  slight  flare,  the  vaginal  rim  should  be  larger. 


OBLITERATION  OF  THE  VAGINA  ;    KOLPOKLEISIS. 

(Fig.  321.)  When  a  vesico-vaginal  fistula  cannot  be 
closed  by  the  means  above  described,  the  escape  of  urine  may 
be  prevented  by  closing  the  vagina.  Vidal  de  Cassis  first 
performed  this  in  1833  by  eff'ecting  union  between  the  labia 
majora,  but  it  has  been  found  that  complete  closure  cannot 
be  thus  obtained,  a  small  opening  remaining  at  the  lower 
angle.  Simon's  method  of  uniting  the  anterior  and  poste- 
rior walls  of  the  vagina  instead  of  the  labia  is  much  more 
trustworthy.     It  w^as  first  performed  in  1855. 

A  strip  of  mucous  membrane  encircling  the  vagina  just 
below  the  fistula  is  removed,  the  opposing  raw  surfaces 
brought  together  by  sutures,  and  the  bladder  kept  empty  by 
a  catheter  until  union  has  taken  place. 


ELYTRORAPHY,  OR  NARROWING  OF  THE  VAGINA. 

This  is  an  operation  intended  to  prevent  prolapse  of  the 
uterus.*  The  method,  introduced  by  Sims,  of  removing  a 
longitudinal,  strip  of  mucous  membrane  from  each  side  of 
the  vagina,  and  bringing  the  raw  surfaces  together,  has 
proved  not  only  inefficient,  but  often  actually  harmful  by 
supplying  a  pouch  in  Avhich  the  cervix  became  engaged, 
thus  causing  extreme  retroversion.  Dr.  Emmet  avoided 
this  detect  by  closing  the  pouch  at  its  upper  end,  but  the 
mechanical  difficulties  in  the  way  of  performing  the  opera- 
tion are  so  great  that  he  has  substituted  for  it  another  in 

40 


470      OPERATIONS    ON   GEN  ITO  -  U  RIN  A  R  Y   ORGANS. 


which  he  catches  up  on  a  tenaculum  three  folds  of  the  vaginal 
mucous  memhrane,  one  on  each  side,  and  the  third  in  fi-ont 
of  the  cervix  (Fig.  322),  denudes  them  over  a  space  half  an 
inch  square,  and  draws  them  together  with  a  suture.  The 
three  folds  radiating  from  these  points  are  then  pared,  and 
united  stitch  by  stitch  along  the  anterior  wall  of  the  vagina. 
Dr.  Thomas  suggests^  a  method  which,  he  thinks,  pro- 
mises well.     It  may  be  performed  upon  either  vaginal  wall, 

Fig.  322. 


Emmet's  operation  for  procidentia. 

or  on  both  in  two  successive  operations.  AVhile  doing  it, 
the  uterus  may  be  left  in  complete  prolapse,  or  it  may  be 
previously  returned  to  the  pelvis. 

Suppose  an  operation  on  the  anterior  wall,  the  uterus 
prolapsed.     Dorsal  decubitus.     The   mucous  membrane  of 

^  Diseases  of  Women,  4th  edition,  p.  ob4. 


K  L  V  T  R  C)  1{  A  r  H  Y  ,  O  K   N  A  H  R  O  W  1  N  O   ()  K    VAGINA.      471 

the  vagina  half  an  incli  from  one  side  of  the  cervix  is  pinclied 
up,  and  a  small  hole  made  in  it  through  which  a  grooved  direc- 
tor is  ]>assed  directly  across  the  anterior  face  of  the  uterus, 
between  it  and  the  vagina,  to  the  corresponding  })oint  on  the 
other  side  of  the  cervix.  Upon  this  director  the  vagina  is 
cut  transversely.  The  director  is  again  entered  at  the 
centre  of  the  transverse  incision,  worked  up  through  the 
loose  areolar  tissue  between  the  bladder  and  vagina  nearly 
to  the  meatus,  and  then  withdrawn.  A  steel  instrument 
(Fig.  323),  as  large  as. a  No.  9   sound,  with   blades  three 


Fig.  323. 


G.T  lEMAKN-CO. 
Thomas's  dilating  forceps. 


inches  long,  is  passed  along  the  channel  made  by  the  direc- 
tor and  opened  forcibly  so  as  to  tear  the  subcutaneous  tissue 
and  separate  the  bladder  from  the  vagina  over  a  triangular 
space,  the  apex  of  which  is  near  the  meatus  and  the  base 
at  the  cervix. 

The  ends  of  the  transverse  incision  are  then  brought 
together  by  -a  suture,  the  result  being  that  the  loosened 
triangular  portion  of  mucous  membrane  hangs  down  and 
forms  a  lonfjitudinal  fold ;  this  fold  is  encracjed  between  the 
blades  of  a  toothed  clamp  three  inches  long  and  half  an  inch 
wide  (Fig.  324)  placed  with   its  hinge  at  the  cervix  and 

Fig.  324. 


tightened  by  means  of  the  screw.  Then  the  portion  of  the 
vaginal  mucous  membrane  hanging  out  of  the  clamp  is  cut 
off,  the  edges  of  the  wound  brought  together  with  interrupted 
silver  sutures,  and  the  uterus  returned  with  the  clamp  still 
in  place.     The  vagina  is  then  firmly  plugged  with  cotton, 


472      OPERATIONS   ON   GENITO-U  RI N  A  R  Y  ORGANS. 

wet  with  a  solution  of  alum  and  carbolic  acid,  to  prevent 
hemorrhage;  this  plug  should  be  removed  at  the  end  of 
twenty-four  hours,  the  clamp  after  forty-eight  hours,  and 
the  sutures  in  eifdit  or  nine  davs. 

For  the  operation  upon  the  posterior  wall  of  the  vagina, 
or  when  the  uterus  is  in  place,  the  transverse  incision  at  the 
cervix  should  not  be  made,  the  dilating  forceps  being  passed 
in  the  opposite  direction. 


LACERATED  CERVIX. 

Dr.  Thomas  Addis  Emmet^  was  the  first  to  point  out  that 
after  laceration  of  the  cervix  the  lips  rolled  out,  their  mu- 
cous membrane  became  eroded  by  contact  with  the  floor  of 
the  pelvis,  and  that  the  proper  method  of  treatment  was  to 
freshen  the  torn  surfaces  and  bring  them  together  with 
sutures,  so  as  to  restore  to  the  cervix  its  normal  size  and 


Fig.  325. 


Fig.  326. 


Lacerated  cervix.    Side 
Tiew. 


Lacerated  cervix      Showing  dcuuded  surface  (the 
shaded  part  and  sutures. 


form.  In  cases  which  have  long  remained  unrecognized  or 
untreated,  the  lips  become  centrally  enlarged  by  the  inflam- 
matory process,  so  that  they  cannot  be  properly  brought 
together  until  after  the  removal  of  a  thick  piece  on  each 
side  of  the  inside  of  each  lip  (Figs.   325  and  32(3).     In 

1  American  Journal  of  Obstetrics,  Nov.  1874. 


LACEKATKD    CERVIX.  473 

like  inaiiiRT,  when  tlic  eversion  is  increased  and  the  coapta- 
tion of  the  lips  prevente<l  by  cystic  degeneration  of  the 
mucous  follicles  linin^r  the  cervic-il  c:inal,  and  by  vascular 
en(Tor«T^ement  due  to  the  inllamniation  and  to  a  constriction 
by  the  everted  edge  of  the  cervix,  similar  to  that  observed 
in  paraphimosis,  free  punctures  must  be  made  with  the 
point  of  a  knife  to  let  out  the  blood  and  the  contents  of  the 
cysts.  It  is  well  to  do  this  several  days  or  weeks  before  the 
operation,  apply  tincture  of  iodine  to  the  cervix,  and  bring 
the  lips  together  temporarily  by  putting  a  plug  of  cotton 
into  the  posterior  cul-de-sac  and  leaving  it  there  for  several 
hours  at  a  time.  The  puncturing  and  application  of  iodine 
must  be  frequently  repeated  until  the  cysts  shall  have 
all  disappeared  and  the  erosions  become  nearly  or  entirely 
healed. 

The  patient  is  placed  on  her  left  side,  a  Sims's  speculum 
introduced,  and  a  loop  of  wire  placed  around  the  cervix 
above  the  vaginal  reflection  and  tightened  by  drawing  its 
ends  down  through  a  canula  so  as  to  prevent  bleeding ;  or 
an  injection  of  hot  water  just  before  the  operation  will  answer 
the  same  purpose.  The  lips  are  then  separated  and  the 
lacerated  surfaces  thoroughly  freshened  with  curved  or  angu- 
lar scissors  or  a  knife,  leaving  a  broad  undenuded  strip  in 
the  centre  to  form  the  lining  of  the  restored  canal.  This 
strip  should  be  shaped  somewhat  like  an  hourglass  in  order 
to  allow  for  the  shrinking  of  the  cervix  which  follows  the 
operation  (Fig.  326).  The  freshening  should  be  done  from 
below  upward,  so  that  the  blood  may  not  interfere,  and  must 
be  carried  deeply  enough  to  remove  all  diseased  glands  and 
follicles. 

A  tenaculum  is  then  engaged  in  each  lip,  and  the  two 
drawn  together  ;  if  proper  coaptation  is  prevented  by  the 
central  enlargement  of  the  cervix  above  mentioned,  simple 
fi-eshening  of  the  surface  is  liot  sufficient,  but  a  greater 
thickness  of  tissue  must  be  removed.  The  fi*eshening  at 
the  angles  of  the  fissure  should  be  superficial,  so  as  not  to 
involve  the  circular  artery  which  often  lies  just  at  that  point. 
The  sutures  should  be  of  silver  wire,  and  passed  with  a 
short,  round  needle  if  the  tissues  are  soft,  or  with  a  lance- 
shaped  one  if  they  are  dense  and  indurated.  From  three 
to  five  will  be  needed  on  each  side  if  the  laceration  is  ex- 

40* 


474      OPERATIONS  ON   G  EN  ITO-U  KIN  A  R  Y   ORGANS. 

tensive  and  double.  The  first  one  on  each  side  should  be 
entered  just  beyond  the  angle  of  the  fissure  so  as  to  include 
the  branches  of  the  circular  artery  if  necessary.  The  needle 
is  entered  on  the  outside  of  the  lip  and  brought  out  at  the 
edge  of  the  undenuded  strip  which  is  to  form  the  canal,  and 
then  passed  in  the  opposite  direction  (from  within  outward) 
at  corresponding  points  through  the  other  lip.  Care  must 
be  taken  to  obtain  accurate  approximation  along  the  vaginal 
edge,  but  the  inner  edges  of  the  denuded  surfaces  do  not 
require  attention. 


POSTERIOR  SECTION  OF  THE  CERVIX. 

This  operation  may  be  rendered  necessary  by  irreducible 
flexion  of  the  uterus.     The  patient  being  placed  in  position 


Fig.  327. 


Slms's  knife. 

Fig.  328. 


Posterior  section  of  the  cervix. 


AMPUTATION    OF    THE    CERVIX    UTERI.       475 

;ni(l  ;i  Sims's  speculum  introducetl,  the  cervix  is  fixed  by  a 
tenaculum  and  its  posterior  lip  divided  with  scissors  as  hiji^di 
as  to  the  vaginal  junction.  The  blade  of  a  Sims's  knife 
(Fig.  327)  is  then  introduced  through  the  os  internum,  and 
the  tissues  cut  so  as  to  lay  open  the  posterior  wall  of  the 
cervix  (Fig.  328).  The  blade  is  then  turned  toward  the 
anterior  wall,  and  the  little  shoulder  which,  as  Dr.  Emmet 
has  pointed  out,  usually  exists  there  at  the  point  of  flexion 
is  cut  through.  Instead  of  making  this  second  incision  Dr. 
Wylie  practises  and  recommends  divulsion  Avith  a  strong 
steel  dilator. 

A  roll  of  cotton  saturated  with  a  solution  of  persulphate 
of  iron,  one  part  to  two  of  water,  is  placed  so  as  to  occupy 
the  whole  cervix,  and  retained  by  a  plug  of  wet  cotton  m 
the  vagina. 

AMPUTATION  OF  THE  CERVIX  UTERI. 

The  cervix  may  be  removed  with  the  bistoury  or  scissors, 
the  ecraseur,  or  the  galvano-cautery. 

Bistoury  or  Seissors.—The  patient  is  placed  in  Sims's 
position,  the  speculum  introduced,  the  cervix  slit  trans- 
versely, and  each  lip  seized  in  turn  with  forceps,  and  cut  oft 
as  near  the  vaginal  junction  as  is  considered  proper.  The 
mucous  membrane  of  the  interior  is  then  drawn  down  and 
made  fast  with  silver  sutures  to  the  outer  edge  of  the  cervix 
so  as  to  cover  in  the  raw  surface.  The  hemorrhage  is  often 
very  severe. 

Ecraseur. — Dr.  Thomas  advises  that  if  the  uterus  is 
prolapsed,  or  if  the  cervix  can  be  protruded  by  moderate 
traction,  the  patient  should  be  placed  on  her  back,  other- 
wise in  Sims's  position.  No  difticulty  will  be  experienced 
in  passing  the  chain  of  the  ecraseur,  but  great  care  must  be 
taken  that  it  does  not  drag  upon  the  neck  without  cutting, 
since  it  sometimes  draws  in  the  peritoneum  or  bladder. 

Galvano-cautery.— DorsdX  decubitus,  or  Sims's  position. 
The  wire  is  passed  around  the  neck  and  tightened  until  it 


476      OPERATIONS  ON  GENITO  -  URIN  A  R  Y   ORGANS. 

is  SO  firmly  fixed  that  it  will  not  slip.  The  current  of  elec- 
tricity is  then  passed  through  it,  and  the  wire  tightened  by 
a  screw  as  it  burns  its  way  through.  Dr.  Thomas  considers 
this  method  greatly  superior  to  the  others. 


OVARIOTOMY. 

The  steps  of  the  operation  are : 

Incision  into  the  peritoneal  cavity. 
Search  for  adhesions. 

Tapping  of  the  cyst  and  rupture  of  adhesions. 
Removal  of  the  sac,  and  treatment  of  the  pedicle. 
Cleansing  of  the  peritoneum. 
Closure  of  the  external  wound. 
Four  or  five  assistants  are  needed :  one  to  stand  oppo- 
site the  operator,  make  pressure  on  the  abdominal  wall,  and 
aid  in  manipulating  the  tumor ;  a  second  to  administer  the 
anaesthetic  ;  a  third,  fourth,  and  fifth  to  tie  ligatures,  hand 
instruments,  clean  sponges,  and  make  pressure  on  the  abdo- 
men if  necessary. 

The  patient  should  be  prepared  for  the  operation  by 
taking  a  gentle  laxative  every  second  day  during  the  pre- 
ceding week  and  enough  opium  the  night  before  to  insure  a 
good  night's  rest.  The  temperature  of  the  room  should  be 
betweeii^T5°  and  80°  Fahrenheit,  and  the  patient  should  be 
dressed  in  flannel  drawers,  wrapper,  and  stockings.  Dorsal 
decubitus,  with  the  legs  hanging  down  over  the  end  of  the 
table  and  the  feet  resting  on  chairs. 


o 


Incision. — The  incision  should  begin  in  the  median  line 
about  six  inches  above  the  symphysis  pubis  and  extend 
about  five  inches  downward.  The  tissues  are  divided  layer 
by  layer,  and  the  bleeding  arrested  as  it  occurs.  When  the 
linea  alba  is  reached  it  must  be  pinched  up,  opened,  and 
divided  upon  a  director,  and  then  the  underlying  peritoneum 
opened  in  the  same  manner.  It  is  not  always  easy  to  recog- 
nize the  peritoneum  or  the  cyst ;  each  has  been  mistaken 
for  the  other,  and  as  the  disadvantages  of  opening  the  cyst 
prematurely  are  far  less  serious  than  those  of  separating  the 


OVARIOTOMY.  477 

peritoneal  from  the  abdominal  wall,  Prof.  Peaslee*  lays 
down  the  rule  that  whenever  there  is  any  doubt  about  it  the 
surgeon  must  act  as  if  the  peritoneum  had  not  been  opened. 
He  also  advises  that  the  incision  into  the  peritoneum  should 
not  at  fii*st  be  more  than  an  inch  and  a  half  long,  since  that 
is  sufficient  to  disclose  broad  lateral  or  anterior  adhesions  if 
they  exist,  and,  generally,  to  complete  the  diagnosis  if  it  has 
been  doubtful :  in  short,  the  incision  should  be  considered 
an  exploratory  one,  until  it  has  enabled  the  surgeon  to  decide 
whether  or  not  to  complete  the  operation. 

Search  for  Adhesions. — This  is  made  with  a  steel  urethral 
sound  previously  dipped  in  hot  water,  which  is  introduced 
through  the  incision  and  swept  around  the  cyst.  It  should 
not  be  used  to  break  the  adhesions,  but  only  to  determine 
their  position,  number,  and  size,  and  to  complete  or  verify 
the  diagnosis,  for  this  is  the  point  at  which  the  operation 
must  be  abandoned,  if  at  all. 

Tappinfi  the  Cyst  and  Rupture  of  the  Adhesions. — 
Prof.  Peaslee  preferred  ''the  simple  trocar  of  various  sizes 
(three  to  five  lines  in  diameter)  and  five  inches  long;  '  Dr. 
Thomas^  uses    Spencer  Wells *s   large  trocar  (Fig.  329)  if 

Fig.  329. 


Sl-encer  Wells's  trocar. 


"  it  is  absolutely  certain  that  the  tumor  is  an  ovarian  cyst, 
and  that  the  prospects  are  decidedly  in  favor  of  it's  suscep- 
tibility of  removal."  Whatever  kind  of  trocar  is  used,  a 
rubber  tube  should  be  attached  to  it  to  carry  the  liquid  to 
the  receivinfr  vessel.     The  trocar  should  be  introduced  at 


1  Ovarian  Tumors,  p.  421. 

2  Diseases  of  Women,  1874,  p.  746. 


478      OPERATIONS    OX   G  EN  1  TO- U  R  IX  A  R  Y   ORGANS. 

the  upper  angle  of  the  incision,  and  the  assistant  should 
make  pressure  upon  the  abdominal  wall  as  the  liquid  runs 
off,  and  should  fill  the  incision  ^vith  sponges  to  catch  any 
that  may  escape  alongside  the  trocar. 

If  there  are  other  cysts,  they  may  be  evacuated  through 
the  original  puncture  by  reinserting  the  trocar  into  the 
canula  and  pushing  it  on  into  them  ;  if  any  difficulty  is  ex- 
perienced in  doing  this,  Spencer  Wells  advises  that  a  free 
incision  be  made  in  the  first  cyst,  and  the  hand  passed 
through  it  to  grasp  and  steady  the  others  while  they  are 
punctured. 

If  adhesions  exist  some  may  be  broken  before  the  evacu- 
ation of  the  contents  of  the  cyst  and  some  afterward ;  if 
the  tumor  is  a  monocyst  and  the  adhesions  slight,  the  steel 
sound  may  be  used  to  break  them,  but  if  they  are  extensive 
and  vascular  other  measures  are  required,  such  as  tearing 
with  the  hand  or  dividing  with  scissors,  the  ecraseur,  or  the 
cautery. 

The  hand,  as  also  any  instrument,  must  be  dipped  in  hot 
water  (98°  Fahr.)  before  it  is  passed  into  the  cavity  of  the 
abdomen.  Prof.  Peaslee  says  the  fingers  of  the  surgeon 
are  the  most  trustworthy  instruments  for  detaching  parietal 
or  omental  adhesions,  and  all  others  of  a  certain  length ;  the 
main  precaution  is  to  detach  them  from  the  surface  of  the 
cyst  and  not  from  the  peritoneum.  Adhesions  between  the 
cyst  and  the  intestines  or  pelvic  organs,  on  the  other  hand, 
are  best  divided  by  scissors.  The  actual  or  galvano-cautery 
is  used  bv  some  in  order  to  avoid  hemorrhage.  Dr.  Peaslee 
objects  to  the  actual  cautery  because  particles  of  the  oxide 
of  i]*on  are  left  behind,  which,  as  foreign  bodies,  are  open  to 
the  only  objection  urged  against  silk  ligatures. 

If  the  cyst  is  intimately  adherent  to  any  organ,  it  should 
not  be  detached,  but  the  adherent  portion  of  the  cyst  wall 
should  be  cut  away  from  the  rest  and  left  attached  to  the 
viscus,  or,  as  Dr.  Peaslee  suggests,  the  peritoneal  lining 
should  be  divided  all  around  the  adhesion  and  the  fibrous 
layer  peeled  off.  If  the  first  plan  is  adopted,  it  is  proper  to 
dissect  off  the  free,  or  secreting,  surface  of  the  adherent 
portion.  If  bleeding  follows  the  division  of  an  adhesion, 
an  antiseptic  silk  or  catgut  ligature  must  be  applied.  If  the 
bleeding  comes  from  a  surface  denuded  of  its  peritoneum, 


OVARIOTOMY.  471) 

and  is  not  arrested  by  exposure  to  tlie  air,  pressure,  or  liga- 
tion, tlie  position  of  the  vessel  \vhicli  supplies  it  may  be 
aseertaiiR'd  by  making  pressure  at  ditVerent  points  anjund 
the  margin  of  the  surface,  and  a  fine  ligature  passed  under 
it  with  a  needle.  In  one  case  Dr.  Peaslee  pinched  up  a  fold 
of  the  abdominal  wall,  including  the  bleeding  surface,  and 
passed  sutures  through  it  on  the  outside,  thus  stopping  the 
hemorrhage  by  the  pressure  of  the  two  sides  against  each 
other.  The  sutures  were  removed  at  the  end  of  the  third  day. 
Omental  adhesions  must  be  divided  between  two  ligatures. 

Removal  of  the  Sac  and  Treatment  of  the  Pedicle. — If 
the  sac  cannot  be  readily  withdrawn  after  the  adhesions 
have  separated,  no  force  must  be  used,  but  a  search  made 

Fig.  330. 


Spencer  Wells's  clamp, 

for  the  cause,  enlarging  the  abdominal  incision  upward  it 
necessary.  During  these  manipulations  and  the  examina- 
tion of  the  pedicle,  Dr.  Peaslee  prevents  leakage  from  the 
sac  by  not  withdrawing  the  canula,  but,  instead,  reinserting 
the  trocar  into  it  and  forcing  it  again  through  the  cyst  wall 
from  within  outward,  a  few  inches  from  the  original  punc- 


480      OPERATIONS   ON  GENITO-URIN A  RY  ORGANS. 

ture.  The  trocar  is  then  withdrawn  and  the  canula  tied  in 
by  throwing  a  strong  ligature  around  the  cyst  below  its  two 
ends.  The  canula  thus  forms  a  sort  of  handle,  and  no  liquid 
can  escape.  Dr.  Thomas  prefers  to  place  a  ligature  or  a 
temporary  clamp  around  the  sac  at  some  distance  from  the 
pedicle  and  then  cut  the  sac  away. 

The  pedicle  may  be  brought  out  at  the  lower  angle  of  the 
incision  and  secured  with  a  clamp  or  ligature,  or  it  may  be 
transfixed  with  a  double  ligature  and  returned,  the  ends  of 
the  ligature  having  been  cut  short.  Many  other  methods 
have  been  employed,  such  as  ligation  or  torsion  of  the  dif- 
ferent vessels,  acupressure,  actual  cautery,  and  the  ecraseur, 
for  a  full  description  of  which  the  reader  is  referred  to  special 
works  on  the  subject.  Practically,  the  numerous  methods 
are  narrowed  down  to  the  ligature  or  clamp  for  long  pedi- 
cles, the  ligature  for  short  ones,  and  enucleation  when  there 
is  no  pedicle. 

Ligatures  should  be  of  silk,  and  in  applying  them  the 
pedicle  should  be  separated  into  two  or  even  three  parts, 
according  to  its  breadth,  two  if  the  breadth  is  four  inches, 
three  if  it  is  six  inches.  It  is  well  to  have  the  loops  include 
each  other,  as  shown  in  Fig.  331.     They  are  most  readily 


Fig.  331, 


Fig.  332. 


applied  by  transfixing  the  pedicle  with  a  mounted  needle, 
having  its  eye  at  the  point,  and  armed  with  a  fine  silk 
thread,  in  the  loop  of  which  the  end  of  the  ligature  is  en- 
gaged (Fig.  332)  and  drawn  back  through  the  pedicle. 
According  to  Dr.  Peaslee  the  needle  should  be  passed  at 
least  three-quarters  of  an  inch  from  the  cyst,  keeping  also 
about  the  same  distance  from  the  uterus,  and  above  all  avoid- 
ing the  plexus  pampiniformis.  There  must  be  no  traction 
upon  the  pedicle  at  the  time  the  ligatures  are  tied,  other- 


OVARIOTOMY.  481 

wise  it  may  ylip  through  them.  Tie  the  ligature  very  tightly, 
cut  the  pedicle  tliree-cjuarters  of  an  inch  from  it,  leave  the 
ends  of  the  lit^atures  lony;  until  readv  to  close  the  incision, 
then  cut  them  short  and  let  the  pedicle  fall  back  to  its 
natural  position,  or  bring  the  stump  into  the  lower  angle  of 
the  wound  and  fix  it  there  by  transfixion  with  two  long 
stout  pins.  In  holding  up  the  pedicle  for  examination,  or 
while  cleaning  the  cavity,  do  not  make  traction  upon  the 
ligatures ;  hold  up  the  pedicle  with  a  tenaculum  inserted  in 
the  stump,  on  the  distal  side  of  the  ligature,  of  course. 

Enucleation  is  recjuired  when  there  is  no  pedicle,  espe- 
cially in  cases  of  solid  or  semi-solid  tumors  Dr.  Thomas^ 
describes  it  as  follows :  The  operator,  cutting  through  the 
sac,  passes  his  hand  and  arm  in  and  discovers  the  lowest 
portion  of  the  sac.  Then  near  the  base  of  the  sac  he  picks 
up  the  peritoneal  covering,  cuts  through  it,  passes  in  his 
finger,  and  removes  the  tumor  by  enucleation.  The  sac 
which  is  left  should  then  be  opened,  thoroughly  cleansed, 
touched  all  over  its  oozing  surface  with  persulphate  of  iron, 
and,  if  large,  tied  around  a  catheter,  which  will  act  as  a 
drainage  tube. 

Cleansing  of  the  Peritoneum. — The  remaining  ovary 
must  next  be  examined,  and,  if  seriously  diseased,  removed. 
Cysts  not  larger  than  a  cherry  may  be  safely  punctured  and 
the  ovary  left. 

It  is  a  matter  of  the  utmost  importance  that  all  liquid 
should  be  removed  from  the  peritoneal  cavity  ;  it  is  not 
probable  that  the  manipulations  required  to  effect  this  ma- 
terially increase  the  chance  of  the  occurrence  of  peritonitis, 
while  it  is  very  certain  that  if  any  liquid  is  left  it  is  likely 
to  undergo  decomposition  and  give  rise  to  septicaemia. 
Carefully  purified  sponges  of  small  size  and  firm  texture 
should  be  used,  and  it  is  well  to  use  not  more  than  two  or 
three  such,  and  in  any  case  to  count  beforehand  the  number 
used,  so  as  to  guard  against  leaving  any  within  the  peri- 
toneal cavitv. 

Closing  the  External  Wound. — Before  closing  the  ex- 
ternal incision  Dr.  Sims  passed  a  drainage  tube  through  the 

^  Diseases  of  Women,  1874,  p.  753. 
41 


482      OPERATIONS   ON  GENITO-U  RIN  A  R  Y   ORGANS. 

posterior  cul-de-sac  into  the  vagina ;  Dr.  Peaslee  was  the 
first  to  employ  this  method,  in  1855,  but  he  afterward  dis- 
carded it  entirely,  as  not  only  ineffectual  but  dangerous. 
He  used  instead,  whenever  he  had  reason  to  anticipate  a 
speedy  accumulation  of  liquid,  a  silver  tube  one-quarter  of 
an  inch  in  diameter  and  about  five  inches  long,  introduced 
through  the  lower  angle  of  the  incision  into  the  posterior 
cul-de-sac.  A  long  strip  of  linen  was  packed  inside  the  tube, 
projecting  about  an  inch  beyond  the  lower  end  to  protect 
the  abdominal  organs  from  contact  with  the  edge.  Dr. 
Thomas  uses  a  glass  tube  half  an  inch  in  diameter  and 
eight  inches  long,  applied  in  the  same  manner  as  Dr.  Peas- 
lee's.  If  septict\Dmia  occurs  he  inserts  a  gum-elastic  catheter 
throuorh  the  tube,  withdraws  the  latter  an  inch  and  injects  a 
stream  of  warm  water  containing  a  drachm  of  chloride  of 
sodium  or  sixteen  grains  of  carbolic  acid  to  the  pint,  until 
the  return  current  runs  clear. 

The  external  wound  is  finally  closed  by  two  sets  of  me- 
tallic sutures,  the  deep  and  superficial.  The  former  may 
be  passed  by  means  of  the  needle  employed  by  Dr.  Peaslee 
to  transfix  and  tie  the  pedicle  (Fig.  332),  or  by  threading 
each  end  of  the  wire  upon  a  needle  and  passing  it  from 
within  outward.  The  sutures  should  pass  through  the 
peritoneum  near  the  edge  of  the  incision  and  emerge  through 
the  skin  about  an  inch  from  the  edge,  and  should  then  be 
tied  over  ivory  rods  or  pieces  of  gum  catheter  (quilled 
suture).  By  including  the  recti  muscles  in  these  sutures, 
the  patient  is  rendered  less  liable  to  hernia  in  the  line  of 
the  incision.  The  superficial  sutures  may  be  interrupted  or 
twisted,  and  should  include  only  the  skin  and  subcutaneous 
cellular  tissue.  Some  surgeons  use  only  one  set  of  inter- 
rupted sutures,  including  the  skin  and  peritoneum,  and 
placed  about  half  an  inch  apart ;  others  close  the  peritoneal 
opening  by  a  continuous  catgut  suture,  and  include  in  the 
silver  sutures  only  the  skin  and  muscular  layers. 

Finally,  two  or  three  strips  of  adhesive  plaster  five  inches 
wide  are  wrapped  entirely  around  the  abdomen,  and  an  anti- 
septic dressing  applied. 


VAGINAL    OVARIOTOMY.  483 


VAdlNAL  OVAKTOTO.MY. 

(Thomas.)  The  irctuin  must  he  thoroughly  em})tie(l,  not 
merely  by  an  enema,  but  also  by  the  finger  if  necessary.  The 
patient  is  then  aiuosthetized  and  placed  in  Sims's  ])OsitioH. 
A  Sims's  speculum  is  introduced,  a  fold  of  the  vaginal  ^vall 
caught  up  on  a  tenaculum  in  the  posterior  cul-de-sac  close 
to  its  reflection  u})on  the  cervix,  and  an  antero-posterior 
incision,  nearly  an  incK  long,  made  in  it  in  the  median  line 
with  a  pair  of  scissors.  The  point  of  the  tenaculum  is  then 
disengaged,  passed  into  the  incision,  and  reengaged  in  the 
areolar  tissue  between  the  vagina  and  peritoneum.  The 
surgeon  cuts  carefully  with  the  scissors  between  the  tenacu- 
lum  and  uterus,  not  antero-posteriorly  but  in  a  direction 
parallel  to  the  posterior  face  of  the  uterus,  changing  the 
position  of  the  tenaculum  as  the  depth  of  the  incision  in- 
creases, until  he  has  reached  and  opened  the  peritoneum. 

He  introduces  his  finger  through  the  opening,  and  brings 
down  the  tumor  or  ovary  of  which  he  is  in  search ;  or  en- 
larges the  opening  transversely  by  tearing,  if  necessary, 
and  introduces  the  whole  hand. 

The  only  operative  risk  is  that  of  cutting  into  the  rectum ; 
and  this  may  be  avoided  by  remembering  that,  although  the 
peritoneum  forming  Douglas's  cul-de-sac  usually  descends 
along  the  upper  portion  of  the  posterior  wall  of  the  vagina 
to  a  greater  or  less  distance  (more  than  an  inch,  according 
to  Tillaux  •/  less  than  half  an  inch,  according  to  Sappey^), 
it  sometimes  does  not  cover  it  at  all,  and,  therefore,  the  dis- 
section must  be  made,  not  directly  backward,  but  upward 
and  inclining:  somewhat  backward  from  the  line  of  the  ute- 
rus.  It  must  also  be  remembered  tliat  the  thickness  of  the 
vagino-peritoneal  septum  is  often  quite  considerable.  This 
operation  is  now  practically  abandoned  because  disease  of 
the  ovary  is  commonly  accompanied  by  disease  of  the  Fallo- 
pian tubes. 

*  Traite  d'Anatomie  Topographique,  p.  966. 
-'  Anatomie  Descriptive,  vol.  iv.  p.  749, 


484      OPERATIONS   ON   GENITO-U  RIN  A  R  Y  ORGANS. 


VAGINAL  HYSTERECTOMY    (SCHROEDER^). 

Having  dragged  the  uterus  forcibly  downward  with  Mu- 
zeux's  forceps,  he  cuts  into  the  connective  tissue  in  front  of 
the  whole  width  of  the  anterior  lip  of  the  cervix,  and  sepa- 
rates the  bladder  from  the  cervix,  then  cuts  through  the 
posterior  vaginal  vault,  so  that  the  cervix  is  freed  on  all 
sides,  and  opens  Douglas's  space.  Cutting  with  scissors, 
he  extends  the  opening  to  the  utero-rectal  ligaments,  and 
introduces  two  fingers  into  the  cavity,  over  the  uterus,  and 
into  the  utero-vesical  pouch,  and  on  them  divides  the  peri- 
toneum in  front.  By  combined  manipulation  the  uterus  is 
retroverted.  and  the  fundus  brought  through  the  posterior 
wound  to  the  vulva  by  traction  with  the  forceps.  The  liga- 
tion of  the  broad  ligaments  must  be  so  managed  that  the 
lio-atures  will  not  slip  when  the  uterus  is  cut  away ;  this  is 
quite  difiicult  when  the  entire  removal  of  the  tubes  and 
ovaries  with  the  uterus  is  undertaken,  but  is  much  easier 
when  the  uterus  alone  is  removed.  Schroeder  usually  ties 
en  masse  on  each  side,  and  then  applies  two  additional  liga- 
tures close  to  the  first  one,  one  for  the  upper,  and  the  other 
for  the  lower  part  of  the  broad  ligament.  It  may  be  best 
to  divide  the  broad  ligaments  close  to  the  uterus,  and  re- 
move the  ovaries  as  a  separate  step.  The  division  of  one 
broad  ligament  much  facilitates  ligation  of  the  other. 

A  winged  drainage  tube  is  placed  in  the  centre  of  the 
wound,  and  the  lateral  portions  are  brought  together  without 
any  attempt  to  secure  nice  coaptation  of  the  peritoneum. 


HYSTEROTOMY. 

(Csesarean  Section.)  The  preparation  and  position  are 
the  same  as  for  ovariotomy.  The  incision  should  begin  in 
the  median  line  a  little  below  the  umbilicus,  and  end  about 
two  inches  above  the  symphysis  pubis.  The  tissues  are 
divided  layer  by  layer,  bleeding  arrested  as  it  occurs,  and 

1  This  description,  slightly  altered,  is  taken  from  Emmet's  Gyne- 
cology, 1884,  p.  530. 


G  A  ST  K  U  -  E  L  Y  '1"  K  O  T  ()  M  Y  .  485 

till'  pcritoiieuiii  ojti'iiod  iipoii  a  director,  while  two  assi.stants 
make  steady  pressure  upon  the  ahdoinen  above  and  below  to 
keep  the  abdominal  uterine  walls  in  close  ai)position. 

As  it  is  impossible  to  determine  the  position  of  the  i)la- 
centa  beforehand,  the  incision  of  the  uterus  must  be  made 
in  the  median  line  between  the  fundus  and  cervix,  not  in- 
volving these  two  parts,  because  their  circular  fibres,  if 
divided,  would  retract  and  cause  the  wound  to  gape.  As 
the  inner  surface  of  the  uterus  is  approached,  the  successive 
cuts  must  be  made  widi  caution  lest  the  placenta  should 
chance  to  lie  underneath  and  be  injured ;  if  it  is  met  with, 
the  surgeon  must  detach  it  carefully  on  one  side  before 
attempting  to  remove  the  child. 

If  the  membranes  are  intact,  the  escape  of  the  amniotic 
liquid  must  be  guarded  against  at  the  moment  of  their  per- 
foration by  making  the  opening  small,  and  the  liquid  must 
be  prevented  from  running  into  the  peritoneal  cavity.  The 
orifice  is  then  enlarged,  the  child  seized  by  the  feet  and 
extracted.  The  hand  is  passed  into  the  uterus,  the  placenta 
detached  and  withdrawn,  and  finally  a  probang  passed 
through  the  os  into  the  vagina  to  secure  an  outlet  in  tlxat 
direction  for  the  discharges. 

After  the  uterus  has  contracted  down,  and  the  peritoneal 
cavity  has  been  cleaned,  the  incision  in  the  uterus  may  be 
closed,  as  in  Spencer  Wells's  case,  by  a  continuous  suture, 
the  end  of  which  is  brought  out  into  the  vagina,  or  it  may 
be  left  ununited.  The  abdominal  incision  must  be  closed 
with  silver  sutures  as  after  ovariotomy. 


(JASTRO-ELYTROTOMY. 

The  operation,  which  now,  thanks  to  Dr.  Thomas,  is  again 
upon  trial,  with  a  fair  prospect  of  becoming  the  substitute 
not  only  for  Caesarean  section  but  also  for  craniotomy  in 
some  cases,  was  first  performed  by  Ritgen  in  1820.^  In 
1806,  1822,  and  1823,  the  same  operation  was  suggested 
independently  by  two  other  obstetricians,  and  attempted  by  a 
third,  Baudelocque,  who,  however,  abandoned  it  for  Csesarean 

^  Thomas  on  Gastro-Elytrotoniy,  Am.  Journ.  of  Obstetrics,  1871, 
p.  12o. 

41* 


486      OPERATIONS  ON   GE  NITO- U  K  I  N  A  R  Y   ORGANS. 

section.  Nothing  more  ^as  then  heard  of  it,  except  in  con- 
demnation by  Yelpeau,  until  early  in  1870  ^-hen  Dr.  Thomas 
performed  it  upon  a  woman  dying  of  pneumonia  in  the  seventh 
month  of  pregnancy.  Fortunately,  the  distinguished  gyne- 
cologist was  fully  prepared  for  the  emergency ;  he  had  con- 
ceived the  plan  of  the  operation,  in  ignorance  of  its  history, 
several  years  before,  and  had  rehearsed  it  upon  the  gravid 
as  well  as  the  non-gravid  cadaver. 

Since  that  time  it  has  been  performed  twice  by  Dr. 
Skene,  of  Brooklyn,  and  once  by  Dr.  Thomas,  with  most 
gratifying  results,  as  the  following  record  shows. 

First  Case. — Dr.  Thomas.  Performed  in  the  interests 
of  the  child,  the  mother  being  moribund  at  the  time  of  ope- 
ration.     Child  safely  and  easily  delivered. 

Second  Case. — Dr.  Skene.  In  the  interests  of  the  mother, 
craniotomy  having  been  previously  performed.  Mother  re- 
covered. 

Tidrd  Case. — Dr.  Skene.     Both  mother  and  child  lived. 

Fourth  Case. — Dr.  Thomas.  Both  mother  and  child 
lived. 

Dr.  Thomas  describes  the  operation  as  follows  :^ 

1.  The  operator  should  be  provided  with  a  pocket  case  of 
instruments,  a  blunt  hook,  steel  sound,  cautery  irons,  ether, 
persulphate  of  iron,  and  Barnes's  dilators. 

2.  The  patient,  having  been  anaesthetized,  should  be 
placed  on  a  firm  table,  and  the  os  fully  dilated  by  Barnes's 
dilators. 

3.  An  incision  should  be  made  with  a  bistoury  through 
the  skin  of  the  abdomen  (preferably  on  the  right  side) 
parallel  to,  and  a  finger's  breadth  above,  Poupart's  liga- 
ment, and  extending  from  the  spine  of  the  pubis  to  the  an- 
terior superior  spinous  process  of  the  ilium.  This  incision 
is  carried  down  through  the  different  layers  as  for  ligature 
of  the  common  iliac,  and  when  the  peritoneum  is  reached  it 
is  pressed  upward  and  inward,  and  the  fingers  passed  down 
into  the  wound  to  the  vagina  at  its  junction  with  the  cervix. 
A  large  steel  sound  is  then  passed  into  the  vagina  as  far  as 
the  cervix  by  an  assistant,  the  wall  of  the  vagina  pressed  up 
into  the  abdominal  wound,  the  beak  of  the  sound  cut  down 

1  Loc.  cit.,  pp.  130  and  139. 


REMOVAL    OF    FALLOPIAN    TUBES.  487 

upon,  the  opening  enlarged  with  the  fingers,  and  the  sound 
withdrawn. 

4.  The  cervix  is  drawn  up  into  the  iliac  fossa  by  an 
assistant  with  a  blunt  hook,  the  fundus  of  the  uterus  de- 
pressed in  the  opposite  direction,  and  the  operator  pas-ses 
his  right  hand  into  the  open  cervix  and  delivers  the  child, 
turning  it  if  the  head  presents,  extracting  it  if  the  breech 
presents. 

5.  The  iliac  fossa  should  be  cleaned  with  a  stream  of  tepid 
water  introduced  through  the  abdominal  wound  and  escaping 
through  the  vagina,  ligatures  applied  to  bleeding  vessels,  or, 
if  that  is  impossible,  a  metallic  vaginal  speculum  introduced 
through  the  abdominal  wound,  and  the  actual  cauterv  care- 
fully  applied.  If  liemoiThage  should  continue  after  the 
abdominal  wound  has  been  closed  by  suture,  the  uterus 
should  be  excited  to  firm  contraction,  and  a  sponge,  wet 
with  a  solution  of  persulphate  of  iron  introduce<l  through  the 
vagina,  and  placed  in  contact  with  the  bleeding  point,  or  the 
vagina  tamponed. 

6.  Should  no  hemorrhacre  occur,  the  vacjina  should  be 
sponged  out  eveiy  twelve  hours  with  a  weak  solution  of 
carbolic  acid. 


REMOVAL  OF  THE  FALLOPIAN  TUBES  AND  OVARIES. 
*'TAIT*S  OPERATION." 

A  small  incision  is  made  in  the  median  line  midway  be- 
tween the  umbilicus  and  pubes,  and  carried  down  to  the 
peritoneum.  All  bleeding  is  arrested,  and  then  the  peri- 
toneum carefully  opened  upon  a  director.  The  index  and 
middle  fingers  are  passed  to  the  fundus  of  the  uterus,  and 
thence  along  the  back  of  each  broad  ligament  to  explore  the 
tubes  and  ovaries.  If  the  tube  is  found  greatly  distended  it 
should  now  be  emptied  with  the  aspirator.  If  the  ovary  is 
deeply  covered  in  by  the  broad  ligament  it  can  be  readily 
exposed  by  unrolling  the  ligament  from  behind  forward.^  If 
there  are  adhesions  they  must  be  gently  separated,  or  tied 
and  cut ;  it  will  perhaps  be  necessary  to  enlarge  the  abdom- 
inal incision  for  this  purpose. 

»  Wylie,  Dis.  of  the  Fallopian  Tubes,  p.  20. 


488  MISCELLANEOUS    OPERATIONS. 

If  the  ovary  is  free,  or  after  it  has  been  freed,  it  is  drawn 
into  the  incision,  and  the  loop  of  a  double  antiseptic  silk 
ligature  passed  through  the  broad  ligament  below  it  and 
divided ;  the  two  ligatures  are  then  crossed  and  tied,  one  on 
each  side,  and  the  ovary  and  tube  cut  away.  The  peritoneum 
must  then  be  most  carefully  cleaned,  and  the  abdominal 
incision  closed,  as  described  under  Ovariotomy. 


CHAPTER  IX. 

MISCELLANEOUS  OPERATIONS. 
SPLENOTOMY. 

As  this  operation  has  only  been  performed  a  few  times, 
and  under  circumstances  which  greatly  altered  the  normal 
anatomical  relations  of  the  parts,  it  seems  more  desirable 
to  describe  the  operations  as  performed  than  to  attempt  to 
lay  down  formal  rules  for  its  performance.  In  Pean's  first 
case,^  Sept.  6,  1867,  the  operation  was  begun  under  the 
impression  that  the  tumor  which  it  was  designed  to  remove 
was  an  ovarian  cyst.  The  incision  was  made  from  the  um- 
bilicus to  the  symphysis  pubis,  the  omentum  was  found 
covering  the  tumor,  and  so  adherent  that  the  cyst  had  to  be 
punctured  through  it.  As  soon  as  it  became  clear  that  the 
cyst  was  not  connected  with  the  pelvic  organs  the  incision 
was  carried  four  finger-breadths  higher  along  the  left  side 
of  the  linea  alba,  and  when  it  was  found  to  have  its  origin 
in  the  spleen,  the  gastro-splenic  omentum  was  tied  in  four 
parts  with  metallic  ligatures  and  divided  with  the  actual 
cautery.  The  ligatures  were  cut  short,  the  abdominal  inci- 
sion closed,  and  the  patient  made  a  good  recovery. 

In  his  second  case,  the  diagnosis  of  hypertrophy  of  the 
spleen  was  made ;  it  was  operated  upon  April  25,  1876, 
and  is  reported  in  the  Bulletin  de  V Academie  de  Medeeine 
for  1876,  p.  725.     The  incision  extended  from  the  pubes 

1  Gazette  Medicale  de  Paris,  1867,  p.  738. 


EXTIRPATION    OF    THE    KIDNEY.  489 

to  the  epigastrium  ;  the  omentum,  which  covered  the  tumor, 
was  pushed  aside  and  the  spleen  discdosed,  extt-nfhng  from 
the  left  hyp<K'hondrium  to  the  right  iliac  fossa.  The  gastro- 
splenic  omentum  was  ligatured  en  ntaxse,  divided,  and  the 
stump  brought  out  at  the  lower  angle  of  the  wound.  The 
patient  recovered. 

Dr.  Watson^  also  removed  an  hypertrophied  spleen  weigh- 
ing more  than  ten  pounds,  and  the  patient,  a  young  man, 
recovered.  Dr.  Watson  transfixed  the  gastro-splenic  omen- 
tum with  a  double  ligature,  and  tied  it  in  two  portions. 

Professor  Billioth  removed  an  enlarged  spleen,  at  Vienna, 
in  January.  ISTT."  He  says  the  operation  is  simpler  and 
easier  than  most  (tvariotomies.  His  incision  was  in  the 
median  line,  and  extended  from  a  hands  breadth  above  to  a 
hand's  breadth  below  the  umbilicus.  The  tissues  were  divided 
layer  by  layer,  and  all  bleeding  arrested  before  the  perito- 
neum was  opened.  The  omentum  and  intestines,  which  were 
found  lying  behind  the  si»leen,  were  held  back  with  broad 
flat  sponges,  and  the  spleen  slowly  pressed  out  through  the 
incision.  The  gastro-splenic  omentum  was  tied  in  six  por- 
tions with  hempen  ligatures,  and  a  second  set  applied  nearer 
the  spleen,  so  that  there  should  be  no  escape  of  blood  when 
the  intermediate  portion  was  divided  by  the  knife.  One 
.small  artery  in  the  omentimi  proved  to  be  insufficiently  com- 
pressed and  required  a  separate  ligature.  The  ligatures 
were  cut  short,  the  peritoneum  cleaned  of  all  blood  and 
liquid,  two  drainage  tubes  passed  down  to  the  pedicle,  and 
the  external  wound  closed  by  means  of  thirteen  deep  and 
four  superficial  sutures.  Four  hours  afterwards  the  patient 
died  of  hemorrhaore,  one  of  the  licratures,  which  included 
the  tail  of  the  pancreas,  having  slipped  off. 

EXTIRPATION  OF  THE  KIDNEY. 

A.  From  Behind. — The  kidneys  extend  from  the  lower 
border  of  the  eleventh  dorsal  to  the  upper  border  of  the  third 
lumbar  vertebra,  the  right  lying  a  little  lower  than  the  left, 
and  the  upper  half  or  third  of  each  is  separated  from  the 

1  Edinb.  Med.  Journal,  Feb.  1874. 

'  Wiener  Medizinische  Wochenschrift,  Feb.  3,  1877. 


490  MISCELLANEOUS    OPERATIONS. 

skin  by  the  eleventh  and  twelfth  ribs,  the  diaphragm  and 
the  pleura,  which  extends  down  to  the  lower  edge  of  the 
twelfth  rib,  and,  at  the  side  of  the  spinal  column,  even  below 
it  (Lange).  In  the  interval  between  the  ribs  and  the  ilium 
it  is  covered  by  the  sacro-lumbalis,  the  quadratus  lumborum, 
and  the  lower  end  or  the  aponeurotic  expansion  of  the  latis- 
simus  dorsi  muscles. 

The  incision  is  vertical,  three  or  four  inches  long,  and 
rims  at  a  distance  of  about  three  inches  from  the  spinous 
processes  of  the  vertebn^  from  the  twelfth  rib  to  the  crest  of 
the  ilium.  Its  cutaneous  portion  may  extend  above  the 
twelfth  rib,  and  if  more  room  is  needed  a  second  incision 
may  be  made  from  the  upper  part  of  the  first,  outward,  just 
below  the  twelfth  rib  for  four  or  five  inches.  When  the 
outer  edge  of  the  quadratus  lumborum  is  reached,  the  outer 
portion  of  this  muscle  may  be  divided,  the  sides  of  the 
wound  strongly  retracted,  and  the  fascia  transversalis  incised. 

The  kidney,  thus  exposed,  is  carefully  separated  from  the 
surrounding;  fat,  and  a  strono;  silk  licrature  thrown  over  it 
to  tie  the  renal  vessels  and  the  ureter  en  masse,  and  the 
kidney  cut  away,  leaving  a  small  portion  of  its  substance 
attached  to  the  stump  of  the  vessels  to  prevent  the  slipping 
of  the  liojature.  If  the  bleedino;  still  is  free  the  wound 
should  be  packed. 

B.  From  in  Front. — The  incision  may  be  made  in  the 
median  line  above  or  below  the  umbilicus,  or  at  the  outer 
edge  of  the  rectus  muscle.  The  latter  seems  preferable. 
After  division  of  the  abdominal  wall  in  the  usual  manner 
and  with  the  usual  precautions,  the  intestines  are  held  aside 
with  broad  retractors,  the  peritoneum  covering  the  kidney 
scratched  through  and  detached  along  its  anterior  surface, 
and  a  ligature  passed  with  an  aneurism  needle  around  the 
renal  artery  and  tied ;  a  second  ligature  en  masse  is  then 
thrown  around  all  the  vessels  and  the  ureter  on  the  distal 
side  of  the  first.  The  kidney  is  then  separated  from  its 
envelo23ing  fat  and  removed. 

The  gap  left  by  its  removal  may  be  drained  posteriorly 
through  the  loin,  the  peritoneum  closed  over  it  with  a  con- 
tinuous catgut  suture,  and  the  abdominal  wound  closed ;  or 


SUBCUTANEOUS  OSTEOTOMY.        491 

a  (Irainat^e  tube  may  be  passed  from   tlie  anterior  incision, 
across  the  })eritoneal  cavity,  into  tlie  <2;ap. 

Dr.  W.  8.  Halsted  stitched  tlie  sides  of  the  opening  in 
the  peritoneum  covering  the  kidney  to  the  corresponding 
sides  of  the  anterior  peritoneal  o])ening,  so  as  to  shut  off  the 
peritoneal  cavity  during  tlie  remainder  of  tlie  operation  and 
the  repair  of  the  wound. 


FIXATION  OF  A  MOVABLE  KIDXKY. 

0 

This  is  done  through  the  vertical  lumbar  incision  above 
described.  After  the  kidney  has  been  exposed  it  is  stitched 
fast  with  catgut  or  antiseptic  silk  sutures  to  the  divided  edges 
of  the  fascia  in  the  wound. 


SUBCUTANEOUS  OSTEOTOMY. 

Genu  VaJiiuin. — Ogston,  of  Aberdeen,  Scotland,  in  a 
paper  read  April  4,  1877,  before  the  Deutsche  Gesellschaft 
fur  Chirurgie  meeting  at  Berlin,  and  printed  in  Langen- 
beck's  ArcJu'v,  21st  vol.  p.  542,  proposed  the  following  ope- 
ration for  the  relief  of  the  deformity  known  as  genu  valgum. 

A  small  sharp-pointed  knife,  five  millimetres  broad  and 
seven  centimetres  long,  is  entered  six  or  seven  centimetres 
above  the  tubercle  of  the  adductors  on  the  inner  condyle  of 
the  femur,  exactly  in  the  median  line  of  the  inner  surface  of 
the  thigh,  and  passed  obli(|uely  downw-ard  and  outward 
across  the  front  of  the  condyles,  the  edge  directed  toward 
the  bone,  until  the  point  reaches  the  groove  between  the  con- 
dyles within  the  cavity  of  the  joint  (Fig.  388).  The  knife 
is  then  withdrawn,  and  made  to  cut  down  to  the  bone  on  its 
w^ay  out,  enlarging  the  cutaneous  incision  to  eight  or  ten 
millimetres. 

A  narrow,  pointed  saw  is  then  introduced  carefully  through 
the  incision.  When  the  patella  is  dislocated  outward,  the 
point  of  the  saw  can  be  felt  in  the  groove,  but  if  the  patella 
is  not  dislocated,  it  must  be  lifted  up  and  the  point  of  the 
saw  passed  under  it.  The  bone  is  then  sawni  nearly  through 
with  short  careful    strokes    directly  backward,  care    being 


492 


MISCELLANEOUS  OPERATIONS. 


taken  to  cut  the  harder  shell  at  the  upper  end  of  the  line  of 
section  to  the  same  extent  as  the  softer  bone.  When  the 
section  is  thought  to  have  nearly  reached  the  posterior  sur- 
face of  the  bone,  the  saw  is  withdrawn,  and  the  condyle 
broken  off  and  pushed  upward  by  straightening  the  tibia  on 


Fig.  333. 


Fig.  334. 


Genu  valorum. 


A-^^^ 


Genu  valgum. 


the  femur  (Fig.  334).     The  wound  is  closed  and  the  limb 
put  up  in  plaster. 

This  operation  has  now  been  superseded  by  transverse 
division  of  the  shaft  close  above  the  condyles. 

Shaft  of  a  Long  Bone. — This  is  an  operation  which  has 
recently  come  into  favor,  and  has  been  extensively  practised 
in  England  and  Germany,  especially  to  correct  rachitic 
deformities.  The  names  of  Maunder  and  Adams  are  espe- 
cially associated  with  it  in  the  former  country,  those  of 
Billroth  and  Xussbaum  in  the  latter.  In  France,  the  ope- 
ration was  brought  before  the  profession  by  a  paper  sent  to 
the  Societe  de  Chirurgie,""  by  Boeckel,  of  Strasburg,  contain- 
ing an  account  of  nine  cases  of  his  own  and  twenty-five 
others  which  he  had  collected.  All  had  been  successful.  In 
the  discussion  which   followed    Tillaux's   report  upon  this 


1  Bulletins  de  la  Societe  de  Chirurgie,  1876,  p.  167. 


ERECTILE    TUMORS 


493 


paper,  the  surgeons  generally  expressed  themselves  in  favor 
of  the  operation,  but  thought  the  preference  should  be  given 
to  straightening  by  mechanical  means  whenever  the  bones 
are  soft  enough  to  yield. 

The  operation  is  performed  by  making  a  straight  incision 
<lown  through  the  soft  parts  and  periosteum,  then  raising 
the  edges  of  the  latter  sufficiently  to  allow  the  chisel  to  be 
applied,  and  cutting  through  the  bone  with  a  few  blows  of 
a  mallet.     The  chisel  is  to  be  preferred  to  the  saw. 

Billroth  makes  only  a,  partial  section  with  the  chisel,  and 
completes  it  by  breaking  the  bone  after  the  external  wound 
has  healed.  It  must  be  determined  by  the  peculiarities  of 
each  case  whether  the  incision  shall  be  upon  the  concave  or 
the  convex  side  of  the  bent  bone ;  if  upon  the  concave, 
shortening  is  avoided  ;  if  upon  the  convex,  a  wedge  of  bone 
may  have  to  be  removed. 

For  the  application  of  this  operation  to  deformity  at  the 
hip,  see  An>-hi/Iosis  of  th*-  Hip-joint,  P^ge  !•'♦->• 


ERECTILE  TUMORS. 


The  usual    methods  of  treating   erectile   tumors  are  by 
the   ligature,  caustic,  cautery,  and   coagulating    injections. 

Fig.  335. 


SabcntaDeooB  ligature  of  nsertu. 
42 


494 


MISCELLANEOUS  OPERATIONS. 


Phvsick  cured  one  upon  the  finger  by  circumscribing  it  with 
a  deep  incision. 

Ligatures  should  be  so  applied  as  to  cut  off  the  supply  of 
blood'  entirely.     Figs.  eSA,  336,  337,  338,  and  339  repre- 


FiG.  330. 


Subcutaneous  ligature  of  nttvus.     The  uoeille  passed  under  the  tuniur ;  one  thread 

divided. 

sent  good  methods.  The  caustic  treatment  is  applicable  to 
small  nsevi :  nitric  acid,  or  the  acid  nitrate  of  mercury,  may 
be  used.  The  actual  cautery  is  applied  by  passing  white- 
hot   needles  into  or  through  the  tumor ;  sometimes  a  very 


Fig.  337. 


Fig.  338. 


The  other  end  of  the  divided  thread  passed         The  needle  removed  and  the  nsevus  stran- 
into  the  needle's  eye,  and  the  needle  pa.<sed  gulated  in  quarters, 

through  at  right  angles  to  its  former  direc- 
tion. 


disfiguring  scar  results.  Coagulating  injections  usually 
give  good  results,  but  the  method  is  considered  dangerous 
on  account  of  the  possibility  that  the  coagulation  may  ex- 
tend  into    the  larger  vessels,  and  give    rise   to    embolism. 


BIRTH-M  AKK 


495 


The  solution,  persulphate  of  iron,  should  be  injected,  three 
or  four  dro})s  at  a   time,  at  several   points  by  means  of  a 


Fig.  339. 


Ligature  of  large  nsevus.     Tbe  white  loops  are  divided  on  one  side  and  the  black  on 
the  other,  and  the  corresponding  ends  AA'  and  6B'  tied  together. 

hypodermic  syringe;  or  the  naevus  may  be  incised  longi- 
tudinally and  the  iron  applied  directly  to  the  surface  of 
section. 

BIRTH-MARK. 


Balmanno  Squire^  ha.s  introduced  a  very  simple  method 
of  removing  **  portwine  birth-marks."  He  freezes  the  spot 
with  the  ether  spray  and  makes  a  number  of  fine  parallel 
incisions  from  one-tliirty-second  to  one-sixteenth  of  an  inch 
apart,  and  extending  about  half  through  the  skin,  or  at  most 
to  the  depth  of  one-sixteenth  of  an  inch.  A  piece  of  blot- 
ting paper  is  then  laid  over  the  incisions  and  pressed  steadily 
down  upon  the  skin  for  five  minutes,  with  just  enough  force 
not  to  cause  the  incisions  to  gape.  In  twenty  or  thirty 
minutes  the  blotting  paper  must  be  thoroughly  wet  with 
cold  water  and  removed  by  pulling  it  in  the  direction  of  the 

*  Essavs  on  the  Treatment  of  Skin  Diseases,  No.  III.     London, 
1876. 


496 


MISCELLANEOUS    OPERATIONS. 


cuts  ;  the  underlying  thin  film  of  blood  clot  must  also  be 
gently  and  patiently  washed  off  with  a  camel's  hair  brush. 
If  this  is  properly  done  no  bleeding  will  occur  and  no  scar 
will  be  left,  while  if  the  clot  is  not  removed  it  is  likely  to 
cause  suppuration  and  prevent  primary  union.  In  some 
cases  it  is  necessary  to  make  cross-markings  at  right  angles 
to  the  first  to  effect  a  complete  cure. 

SEPARATION  OF  WEB-FINGERS. 


Experience  has  shown  that  simple  division  of  the  mem- 
brane unitins:  the  two  fino;ers  is  insufficient,  because  re- 
union,  beginning  at  the  angle,  is  certain  to  extend  over  the 
whole  length  of  the  incision.  A  simple  way  of  overcoming 
this  difficulty  is  to  pass  a  leaden  or  silver  wire  through  a 
puncture  made  at  the  interdigital  angle,  keep  it  there  until 
cicatrization  has  taken  place  around  it,  as  around  an  ear- 
ring, and  then  divide  the  membrane.  The  angle  being 
already  cicatrized,  the  lateral  wounds  heal  separately. 

Another  plan  is  to  mark  out  a  palmar  and  a  dorsal  trian- 
gular flap  at  the  interdigital  angle,  its  apex  turned  toward 
the  ends  of  the  fingers  (Fig.  340,  A),  then  to  split  the 

Fig.  340. 


Web  fingers. 


remainder  of  the  membrane  longitudinally,  pare  off  the  end 
of  the  triangular  flaps,  and  unite  them  in  the  interdigital 
angle.  By  this  means  a  bridge  of  integument  is  formed 
which  prevents  reunion  of  the  sides. 


CICATRICIAL   FLEXION   OF  THE   PHALANGES 


497 


These  two  methods  answer  very  well  when  there  is  a  dis- 
tinct interdigital  membrane,  but  some  other  is  required  when 
the  fingers  are  closely  approximated.  The  one  wliich  yields 
the  best  results  is  represented  in  Fig.  340,  B^  and  Fig.  o41. 


Fig.  341. 


A  rectangular  flap  is  dissected  up  from  the  dorsum  of  one 
finger,  and  a  similar  flap  from  the  palmar  surface  of  the 
other  finger,  each  being  left  adherent  by  its  long  side.  The 
fingers  are  then  separated  and  each  flap  turned  in  to  cover 
one  of  the  raw  surfaces. 


CICATRICIAL  FLEXION  OF  THE  PHALANGES. 

The  cicatrix  must  be  divided  thoroughly  to  allow  com- 
plete extension,  and  then  if  skin  flaps  can  be  obtained  from 
the  sides  they  may  be  turned  in  to  cover  the  palmar  surface 
opposite  the  joints.  In  dissecting  up  the  flaps  care  must 
be  taken  not  to  go  deeply  enough  to  involve  the  artery  which 
runs  along  the  side,  otherwise  the  end  of  the  finger  may 
slouch. 

Instead  of  small  lateral  flaps  for  the  flexures  of  the  jomts 
the  skin  covering  the  sides  of  the  finger  may  be  mobilized 
by  lateral  or  dorsal  longitudinal  incisions  and  brought  to- 
gether in  the  median  line  of  the  palmar  surface,  the  gaps 
created  on  the  sides  by  their  removal  being  left  to  heal  by 
granulation. 

Permanent  flexing  of  the  finger  upon  the  hand,  when  due 
to  retraction  of  the  palmar  fascia,  must  be  treated  by  sub- 
cutaneous or  open  division  of  the  fascia. 


42* 


498 


MISCELLANEOUS    OPERATIONS. 


IXIJROWX  TOENAIL. 

If  a  cutting  operation  is  undertaken  the  entire  nail  must 
be  torn  oif  and  tlie  portion  of  the  matrix  adjoining  the  en- 
larged and  indurated  border  cut  away.  Local  anaesthesia 
is  obtained  by  applying  a  mixture  of  pounded  ice  and  salt 
to  the  toe,  or  by  the  ether  spray ;  one  blade  of  a  stout  pair 
of  scissors  is  forced  under  the  nail,  its  edge  turned  upward, 
and  the  nail  divided  along  the  median  line.     Each  half  is 


Fig.  342. 


Ingrown  toenail. 

then  wrenched  out  with  strong  forceps,  and  the  angle  of  the 
matrix  and  the  thickened  skin  along  the  side  of  the  nail 
dissected  off  (Fig.  342).  In  mild  cases  it  is  sometimes  suf- 
ficient to  excise  a  wedge-shaped  piece  from  the  centre  of  the 
fold  of  the  skin  by  two  longitudinal  incisions,  and  draw  the 
sides  of  the  gap  together  by  a  suture  or  strips  of  adhesive 
plaster. 


INDEX. 


ABERNETllY,  ligature  of,external 
^     iliac,  80 
Acupressure,  30 
Adams,  ectropion,  255 

subcutaneous  division  of  neck  o( 
femur,  167 
Agnew,  secondary  cataract,  292 
Alanson,  method  of  amputation,  91 
AUiot,  urethroplasty,  415 
Alquie,  rhinoplasty,  248,  251 
Ammon,  ectropion,  255 

entropion,  262 
Amputation,  90 

Alanson's  method,  91 

circular  method,  90 

flap  method,  92 

long  anterior  flap,  94 

modified  flap,  93 

oval  method,  92,  103,  137 

Teale's  method,  93,  125 

(For  amputation  of  special  part?, 
see  their  names.) 
Amussat,  colotomy,  346 
Amygdalotomy,  304 
Anaesthesia,  general,  26 

local,  25 
Anatomy,  anterior  tibial  artery,  85 

axillary  artery,  63,  64 

brachial  artery,  65 

external  carotid,  71 

femoral  artery,  82 
hernia,  363 

iliac  arteries,  77 

inferior  thyroid  artery,  62 

inguinal  hernia,  360 

intercostal  arteries,  334 

lingual  artery,  74 

muscles  of  the  eye,  393 

oesophagus,  331 

radial  artery,  67 

stomach,  338 

subclavian  artery,  59,  61 

superior  maxillary  nerve,  213 

supra-clavicular  region,  56 

supra-orbital  nerve,  211 

trachea,  329 


Anatomy  {coutinued). 

ulnar  artery,  69 

vertebral  arterj^,  63 
Anchylosis  of  the  elbow,  155 

of  the  hip,  166 

of  the  jaw,  190 
Aneurism  needle,  54 
Anger,  hypospadias,  408 

urethral  fistula,  416 
Ankle,  amputation  at,  114 

comparison  of  methods,  121 

excision,  173 

osteoplastic,  176 
Antiseptic  treatment,  35 
Anus,  closure  of  artificial,  348 

excision,  385 

imperforate,  381 
Aorta,  ligature  of  abdominal,  77 
Arlaud,  urethroplasty,  415 
Arlt,  symblepharon,  264 
Arm,  amputation,  102 
Astragalus,  excision,  175,  206 
Atresia  vaginre,  453 
Auditory  canal,  occlusion,  301 
Aural  speculum,  introduction,  301 
Auvert,  rhinoplasty,  248 
Axillary  artery,  ligature,  63 

BANDAGES,  43 
capelline  or  scalp,  47 
continuous  or  spiral,  44 
figure  of-8  or  spica,  44 
four-tailed,  47 
immovable,  48 
T  bandage,  46 
triangular  bonnet,  47 
Baudens,  colotomy,  346 

disarticulation  of  knee,  129 
Bell,  amputation  of  leg,  lower  third, 
123 
upper  third,  127 
iridotomy,  271 
Berard,  staphyloraphy,  309 
B^renger-Feraud,  suture  of  intestine, 

353 
Bigelow,  lithotrite,  428 


500 


INDEX 


Bigelow  {continued). 

lithotrity  under  ether,  431 
Billroth,  splenotomy,  489 

subcutaneous  osteotomy,  493 
Birth-mark,  495 
Bladder,  exstrophy,  420 

puncture,  424 
Blanchet,  cataract,  274 
Blandin,  rhinoplasty,  241 
Blepharoplasty,  253 

for  ectropion,  253 

for  entropion,  260 

for  pterygion,  265 

for  symblepharon,  263 

for  trichiasis,  266 
Blepharoraphy,  252 
Boeckel,  subcutaneous  osteotomy,  492 
Bonfils,  staphyloraphy,  311 
Bouisson,  hypospadias,  408 

principles  of  rhinoplasty.  248 

suture  of  intestine,  352 
Bowman,  iridotomy,  270 

secondary  cataract,  292 
Brachial  artery,  ligature  of,  65 
Breast,  amputation  of,  333 
Bronchotomy,  325 
Bryant,  colotomy,  346 
Buccal  nerve,  division  of,  218 
Buchanan,  cheiloplasty,  226 
Buck,  cheiloplasty,  227,  232 

collodion  crust,  224 

rhinoplasty,  249 

stomatoplasty,  231 

n^SAREAN  section,  484 
^     Calcaneum,  excision,  204 
Holmes,  204 
Oilier,  205 
Callisen,  colotomy,  346 
Canthoplasty,  253 
Garden,  amputation  at  knee,  130 
Carotid,  ligature  of  common,  70 
of  external,  71 
of  internal,  74 
as  preliminary  to  excision  of 
inferior  maxilla,  187 
•tubercle,  62 
Carpue,  rhinoplasty,  246 
Castration,  390 
Cataract,  277 

depression  or  couching,  278 
division  or  solution,  279 
extraction,  flap,  282 
linear,  288 
scoop,  289 
suction,  290 

Von  Graefe's  method,  285 
with  capsule,  291    ■ 
secondary,  292 


Catheterization  of   Eustachian   tube, 
303 
of  urethra,  422 
in  female,  449 
Cerebral  centres,  localization  of,  207 
Cervix  uteri,  amputation,  475 
laceration,  472 
posterior  section,  474 
Chassaignac,     ligature    of    vertebral 

artery,  63 
Chauvel,  cheiloplasty,  232 

ligature  of  occipital  artery,  76 
Cheiloplasty,  lower  lip,  224 

upper  lip,  232 
Cheselden,  iridotomy,  270 
Chopart's  amputation,  111 
Circumcision,  398 
Clavicle,  excision,  193 
Cloquet,  excision  of  tongue,  323 
Coccyx,  excision,  200 
Collodion  crust,  224 
Colotomy,  345 

Cooper,    Sir   Astley,  ligature    of  ex- 
ternal iliac,  80 
ligature    of    left    subclavian 

artery,  59 
urethroplasty,  415 
Corelysis,  277 
Cornea,  operations  on,_267 
Critchett,  eversion  of  canaliculus,  300 

iridesis,  275 
Cutaneous  sleeve  in  amputation,  91 

D'  EGUISE,  salivary  fistula,  324 
Delavan,  circumcision,  400 
Delpech,  urethroplasty,  415 
Demarquay,  epispadias,  403 
Denonvilliers,  ectropion,  260 

rhinoplasty,  240 
Dental    nerve,   division    of    inferior, 

216 
Desmarres,  iridorhexis,  275 
DiefFenbach,   excision  of  both    supe- 
rior maxillae,  182 

rhinoplasty,  242 
Dolbeau,     dilatability    of     neck     of 
bladder,  435 

epispadias,  403 

ligature  of  external  carotid,  73 

perineal  lithotrity,  447 
Dorsalis  pedis  artery,  ligature,  87 
Dubruel,  amputation  at  wrist,  98 
Duplay,  hypospadias,  410 

perineal  lithotrity,  449 
Dupuytren,  bilateral  lithotomy,  444 

enterotome,  348 

prolapse  of  rectum,  384 

rhinoplasty,  241,  248 


INDEX 


501 


EAR,  operations  on,  301 
Ectropion,  253 

when  due  to  excess  of  conjunc 
tiva,  26U 
Elbow,  amputation  at,  100 
excision,  1 19 

bilateral.  154 
Ilueter,  152 
Nelaton,  152 
Oilier,  151 
osteoplastic,  153 
Von  Langenbeck,  150 
excision  of  anchyloseJ.  155 
Oilier,  155 
"Watson,  156 
partial  excision,  155 
Elytroraphy,  469 

Emmet,  rupture  of  perineum,  455 
creation  of  vesico-vaginal  tistula, 

468 
elytrorapby,  469 
laceration  of  cervix  uteri,  472 
perineoraphy,  454 
post,  section  of  cervix  uteri,  475 
vesico-vaginal  lithotomy,  452 
Enterotomy,  right  inguinal,  343 
Entropion,  260 
Epispadias,  402 
Nelaton,  402 
Thiersch,  404 
Erectile  tumors,  493 
Erichsen,  median  lithotomy,  443 
Esmareh,  anchylosis  of  jaw,  190 

elastic  band,  33 
Estlander,  thorako-plastik,  192 
Eustachian  tube.  3ti3 
Evidement  de  I'os,  144 
Excision  of  joints  and  bones,  general 
considerations,  141 
(For  excision  of  special  joints  and 
bones  see  their  names.) 
Exsector,  143 
Exstrophy  of  bladder,  420 
Eye,  enucleation  of,  296 
evisceration,  26S 
operations  on,  267 
Eyelids,  plastic  operations  on,  252 

FACIAL  artery,  ligature  of,  75 
Fallopian  tubes,  removal,  487 
Femoral  artery,  ligature  of,  >2 
hernia,  strangulated,  363 

Malgaigne's  metho  1, 365 
radical  cure,  366,  376 
Femur,  establishment  of  false  joint, 
169 
excision  of  head,  164,  168 
resection  of  shaft,  201 
subcutaneous  division  of  neck,167 


Fergusson,  staphylorapby,  306 

uranoplasty,  315 
Fibula,  resection,  202 
Fingers,  amputation,  95 

web,  496 
Fissure  of  Rolando,  208 
Fistula,  fecal,  348 

salivary,  324 

urethral,  411 

vesico-vaginal,  462,  468 
Foot,  comparison  of  methods  of  am- 
putation, 121 

excision  of  bones  of,  204 
osteoplastic,  176 
Forcipressure,  31 
Forearm,  amputation,  98 
Frenum  of  penis,  division  of,  402 

of  tongue,  division  of,  323 

GAILLARD.  trichiasis,  261 
Gastro-elytrotomy, 
Gastrostomy,  337 
Gastrotomy,  337 
Gely,  suture  of  intestine,  351 
Genu  valgum,  491 
Gluteal  artery,  ligature  of,  82 
Gosselin,  on  umbilical  hernia,  365 
Graefe,  Von,  blepharoplasty,  258 

cataract,  2^5 

ectropion,  255 

entropion,  261 

trichiasis,  266 
Gritti,  amputation  at  knee,  131 
Gross,  excision  of  scapula,  194 

wounds  of  intestines,  350 
Guerin,  ectropion,  254 

excision  of  anus,  389 

excision  of  superior  maxilla,  179 
Guthrie,    ligature  of  posterior  tibial 

artery,  88 
Guyon,     amputation    of    leg,    lower 
third,  123 

ligature  of  external  carotid,  72 

perineal  lithotrity,  449 

vesico-vaginal  lithotomy,  452 

HARELIP,  complicated,  237 
double.'  236 
single,  234 
llasner,  blepharoplasty,  259 
Flays,  division  of  cataract,  281 
Hemorrhage,  arrest  of,  29 
Heaton,  radical  cure  of  hernia,  381 
Hemorrhoids,  3S9 

Hernia,  radical  cure  by  incision,  366 
by  injection,  381 
of  femoral,  376 
of  inguinal,  367 
by  pins,  373 


502 


INDEX. 


Hernia,  radical  cure  by  incision  {cou- 
tinued). 
of  umbilical,  378 
stangulated  femoral,  363 
inguinal,  360 
obturator,  366 
umbilical,  365 
Herniotomy,  354 

division  of  stricture,  357 
examination  and  return  of  bowel, 

358 
opening  of  the  sac,  356 
recognition  of  sac  and  bowel,  355 
treatment  of  omentum,  359 
Hey's  amputation  of  metatarsus,  111 
Hip,  amputation  at,  135 
Hip-joint,  excision,  16-4 
Oilier,  165 
Roser,  166 
Sayre,  164 
Holmes,    crico-thyroid    laryngotomy. 
327 
excision  of  calcaneum,  204 
of  scapula,  194 
puncture  of  bladder,  424 
suture  of  intestine,  354 
Hueter,  excision  of  elbow,  152 
Humerus,  resection,  197 
Hydrocele,  391 
Hypospadias,  406 

Anger  (Theophile),  408 
Duplay,  410 
Hysterectomy,  vaginal,  484 
Hysterotomy^  484 

TLIAC  artery,  ligature  of    common, 
^  77 

of  external,  80 
of  interna],  80 
Inferior  dental  nerve,  division  of,  216 
Ingrown  toenail,  498 
Inguinal  hernia,  radical  cure,  367 
by  pins,  373 
strangulated,  360 
Malgaigne,  363 
Innominate  artery,  ligature,  57 
Intestines,  suture  of,  349 

of  longitudinal  wound,  350 
of  transverse  wound,  353 
Iridectomy,  271 

antiphlogistic,  272 
in  cataract,  287 
optical,  275 
Iridesis,  275 
Iridorbexis,  275 
Iridotomy,  270 
double,  272 
simple,  271 
Ischgemia,  artificial,  33 


TAW,  anchylosis  of,  190 
^     Jobert,  ligature  of  popliteal  ar- 
tery, 85 
suture  of  intestine,  351,  354 
Jones  ("Wharton),  ectropion,  254 

TT-ELOTOMY,  354 

^^     (See  also  Herniotomy.) 

Iveratonyxis,  279 

Key,  spasmodic  entropion,  262 

Keyes,  circumcision,  398,  400 

Kidney,  extirpation,  489 

fixation,  491 
Knapp,  257,  288 
Knee,  amputation  at,  128 

through  the  condyles,  129 
Garden,  130 
Gritti,  131 
disarticulation,  129 
excision,  170 

Oilier,  171 
extirpation,  172 
Kocher,  excision  of  tongue,  320 
Kolpokleisis,  469 

T  ABBE,  gastrotomy,  340 
^    Lacerated  cervix  uteri,  472 
Lachrymal  apparatus,  operations  on, 
297 
gland,  extirpation  of,  297 
Langenbeck,  Yon,  excision  of  elbow, 
150 
of  shoulder,  147 
of  wrist,  163 
partial  excision  of  superior  max- 
illa, 183 
rhinoplasty,  241 
uranoplasty,  314 
Langenbuck,  excision  of  tongue,  319 
Lannelongue,  gastrostomy,  338 

uranoplasty,  315 
Laparotomy,  341 
Larghi,    excision    of     both     superior 

maxilla?,  179 
Larrey,  amputation  at  shoulder,  103 
of  leg,  126 
rhinoplasty,  241,  248 
Laryngotomy,  crico-thyroid,  327 
sub-hyoid,  326 
thyroid,  326 
Laryngotracheotomy,  328 

St.  Germain's  method,  328 
Laugier,  cataract,  290 

fecal  fistula,  349 
Lee,  amputation  of  leg,  125 
Leg,    amputation,    comparison    of 
methods,  127 
lower  third,  121 
middle  third,  124 


INDEX. 


503 


Leg,  amputation  (continued). 

upper  third,  iL'Ci 
Lembert,  suture  of  intestine,  351 
Ligature    of   arteries,    general   direc 
tions,  53 
(For  ligature  of  special  arte 
ries,  see  their  names.) 
Ligatures,  29 
Lingual  artery,  ligature  of,  74 

nerve,  division  of,  2 IS 
Lisfrane,  amputation  at  shoulder,  105 

rhinoplasty,  248 
Lister,  excision  of  wrist,  159 
Liston,  opening  hernial  sac,  35^" 

rhinoplasty,  242 
Lithotomy,  434 
bilateral,  444 
lateral,  437 
median,  442 
pre-rectal,  445 
recto-vesical,  446 
supra-pubic,  446 
Lithotomy  in  the  female,  451 
urethral,  451 
vesico-vaginal,  452 
Lithotrity,  426 
perineal,  447 

prolonged,  under  ether,  431 
Littre,  colotomy,  345 
Liicke,  excision  of  hip,  166 

sup.  maxillary  nerve,  215 
Lumbar  colotomy,  346 

M  AISONXEUVE,  excision  of  anus, 
^'A         387 

fecal  fistula,  349 
Malgaigne,  cheiloplasty,  229 

resection    of   superior   maxillary 

nerve,  215 
strangulated  hernia,  363,  365 
Mason,  lumbar  colotomy,  346 
Mastoid  process,  trephining,  302 
MaxMla,  inferior,  anchylosis,  190 
excision,  1S6 
superior,  excision,  178 

Oilier,  181 
temporary  resection,  183 
Nelaton,  183 
Von  Lan  gen  beck,  183 
Maxillfe,  excision  of  both,  182 

Larghi,  179 
McBurney,  puncture  of  bladder,  425 

urethrojdasty,  416 
Medio-tarsal  amputation,  111 
Metacarpal  bones,  amputation,  96 

excision.  199 
Metatarsal  bones,  amputation,  109 

excision,  207 
MichoD,  rhinoplasty,  241 


Mikulicz,  176 

Moore,  division  of  lingual  nerve,  21.s 

.Mosetig-Moorhof,  excision   of  elbow, 

154 
Mott,  excision  of  clavicle,  193 

ligature  of  innominate  artery,  57 
Mouth,  operations  on,  224 

^iEVUS,  493 

■'■'      Xeck  operations  on,  325 

X61aton,  epispadias,  402 

excision  of  elbow,  152 

harelip,  235 

pre  rectal  lithotomy,  445 

resection  of  superior  maxilla,  183 

right  inguinal  enterotomy,  343 

staphyloraphy,  311 

urethroplasty,  414 
Neurotomy,  211 

(See  also  the  names  of  the  nerves.) 

OBTURATOR  hernia,  strangulated, 
366 
Occipital  artery,  ligature  of,  76 
(Esophagotomy,  331 
Ogston,  genu  valgum,  491 
Oilier,  excision  of  anchylosed  elbow, 
155 
astragalus,  306 
bones  of  pelvis,  200 
calcaneum,  205 
coccyx,  200 
elbow,  151 
fibula,  203 
hip-joint,  165 
knee-joint,  171 
radius,  198 
scapula,  195 
shoulder,  146 
sternum,  192 

superior  maxilla,  181,  185 
tibia,  201 
wrist,  162 
osteoplastic  rhinoplasty,  249 
periosteal  graft,  239 
Orbit,  extirpation  of  contents,  297 
Osteotomy,  subcutaneous,  491 

Boeckel's  paper  on,  492 
for  anchylosis  of  hip,  167 
for  genu  valgum,  491 
shaft  of  long  bone,  492 
Ovariotomy,  476,  487     .    , 

cleaning  of  peritoneum,  481 
closure  of  external  wound,  481 
enucleation  of  cyst,  481 
incision    into    peritoneal    cavity, 

476 
removal  of  the  sac,  479 
search  for  adhesions,  477 


504 


INDEX 


Ovariotomy  {continued). 

tapping  of  the  cyst,  477 
treatment  of  adhesions,  477 

of  pedicle,  479 
vaginal,  483 

pAGENSTECHER,  cataract,  291 
-^  Paget,  excision  of  tongue,  32.S 
Pancoast,  amputation  at  knee,  129 

rhinoplasty,  245 
Paracentesis  of  abdomen,  336 
of  cornea,  268 
of  membrana  tympani,  302 
of  pericardium,  335 
of  thjrax,  334 
Paraphimosis,  401 
Pean,  splenotomy,  488 
Peaslee,  ovariotomy,  drainage,  4S2 

extent  of  incision,  477 

removal  of  sac,  480 

tapping  cyst,  477 

treatment  of  adhesions,  47S 

of  pedicle,  480 
Pelvis,  resection  of  bones  of,  200 
Penis,  amputation,  396 
Perineal  lithotrity,  447 
Perineoraphy,  454 
Perineum,  rupture  of,  454 

complete,  454,  458 

partial,  454 
Periosteum,  graft  of,  239 
Peters,  excision  of  scapula,  195 
Phalanges,     cicatricial      contraction. 
497 
excision,  199,  207 
Phimosis,  397 

Physick,  erectile  tumor,  494 
Pirogoff's  amputation  at  ankle,  118 
Plaster-of-Paris  bandage,  48 

jacket,  49 
Plastic  operations,  222 

general  principles,  223 
Polyp,  nasopharyngeal,  183 

Boeckef,  184 

Nelaton,  183 

Oilier,  185 

Von  Langenbeck,  183 
Popliteal  artery,  ligature,  85 
Prolapse  of  rectum,  383 

of  posterior  wall  of  vagina,  455 
Prorrhaphy,  296 

Prostate,  incision  in  lithotomy,  41 1 
Pterygion,  265 
Pudic  artery,  ligature  of  internal,  82 

RADIAL  artery,  ligature,  67 
Radius,  excision,  198 
Ranula,  324 
Recamier,  excision  of  anus,  387 


Rectal  etherization,  28 

Rectotomy,  384 

Rectum,  arrest  of  development,  381 

excision,  385 

prolapse,  333 
Regnoli,  excision  of  tongue,  320 
Rhinoplasty,  238 

Indian  method,  246 

Italian  method,  251 

osteoplastic,  244 
Ribs,  resection  of,  192 
Richet,  amputation  of  forearm,  99 

canthoplasty,  253 

ectropion,  256,  259 

umbilical  hernia,  365 
Ricord,  varicocele,  305 
Rigaud,  urethroplasty,  416 

varicocle,  396 
Rizzoli,  anchylosis  of  jaw,  190 
Robert,  prolapse  of  rectum,  384 
Rolando,  fissure  of,  208 
Roosa,  aural  speculum,  301 

catheterization    of    Eustachian 
tube,  303 

paracentesis  of   membrana  tym- 
pani, 302 
R  jux,  staphyloraphy,  308 

tibio-tarsal  amputation,  117 

O  ABIXE,  rhinoplasty,  252 

^  puncture  of  bladder,  426 

Saint  Germain,  laryngo-tracheotomy, 

328 
Salivary  fistula,  324 
Sands,  on  intussusception,  342 
Sayre,  anchylosis  of  hip-joint,  169 
excision  of  hip-joint,  164 
plaster  jacket,  49 
tenotomy,  219 
Scapula,  excision,  194 
of  head,  148 
Schaefifer,  recto-vesical  lithotomy,  422 
I  Schoenborn,  staphyloplasty,  316 
Schroeder,  hysterectomy,  484 
Sciatic  artery,  ligature,  81 
Scleronyxis,  278 

Scymanowski,  urethroplasty,  416 
Sedillot,  amputation  at  ankle,  117,  120 
elbow,  100 
I  forearm,  99 

I  leg,  127 

i  thigh,  134 

cbeiloplasty,  230,  232 
excision  of  tongue,  321 
gastrotomy,  339 
I  ligature  of  innominate  artery,  57 

rhinoplasty,  241 
staphyloraphy,  307 
urethroplasty,  416 


INDEX 


505 


Serre-fine,  42 

Shoulder,  amputation  at,  102 
Larrey,  Id.i 
Lisfranc,  lOJ 
Spence,  100 
excision  of,  145 
Oilier,  146 

transverse  incision,  148 
Von  Langjenbeck,  147 
Simon,  obliteration  of  vagina,  469 

vesico-vaginal   fisitula,  402,  465 
Sims,  drainage  in  ovariotomy,  4<S1 
*        elytroraphy,  469 

speculum,  452 
Skene,  gastro-elytrotomy,  4S6  * 
Smith,  staphyloraphy,  311 
Smyth,   ligature   of    innominate    ar- 
tery, 59 
Spence,  amputation  at  shoulder,  106 

of  thigh, 135 
Splenotomy,  4S8 
Squire,  birth-mark,  495 
Staphyloma,  208 
Staphyloplasty,  816 
Staphyloraphy,  805 
Sternum,  resection,  192 
Stilling,  division  of  nasal  duct,  801 
Stomach,  relations  to  abdominal  wall, 

338 
Stomatoplasty,  230 
Strabismus,  293 

secondary,  296 
Strabotomy,  293 
Streatfeild,  corelysis,  277 
entropion,  263 
slitting  canaliculus,  299 
Subastragaloid  amputation,  113 
Subclavian  artery,  ligature,  59 
Subcutaneous  osteotomy,  107,  491 
Superior  maxillary  nerve,  division  on 
the  face,  213 
resection,  214 
Supra-orbital  nerve,  excision,  211 
Sutures,  39 

continuous,  40 
interrupted,  40 
of  intestine,  349 
quilled,  42 
twisted,  40 
Symblepharon,  263 
Syme,  amputation  at  ankle,  1  14 
of  thigh,  133 
chciloplasty,  220 
excision  of  scapula,  195 
perineal  urethrotomy,  417 
Szokalski,  pterygion,  205 

TAGLIACOZZI,  rhinoplasty,  251 
-*•      Tait,  removal  of  Fallopian  tubes, 

487 


Tarsotomy,  262 
Teale,  amputation  of  leg,  125 
method  of  amputation,  93 
removal  of  cataract    by   suction, 

291 
symblepharon,  204 
Temporal  artery,  ligature,  76 
Tenon,  capsule  of,  293,  297 
Tenotomy,  219 

levator  palpebrae,  221 
peronei,  221 
sterno-mastoid,  221 
tendo  Achillis,  220 
tibialis  posticus,  220 
Thcruio-cautery  in  tracheotomy,  381 
Thigh,  amputation  of,  183 
Thomas,  amputation  of  cervix  uteri, 
475 
elytroraphy,  470 
enucleation  of  ovarian  cyst,  481 
gastro-elytrotomy,  485 
ovariotomy,  480 
rupture  of  perineum,  459 
vaginal  ovariotomy,  483 
vesico-vaginal  fistula,  402 
Thompson,  median  lithotomy,  443 

lithotrite,  427 
Thyroid  artery,   ligature    of   inferior, 

02 
Tibia,  resection,  201 
Tibial  artery,  ligature  of  anterior,  85 

of  posterior,  87 
Tibio-tarsal  amputation  (Syme),  114 
lateral  flap  (Roux),  117 
Pirogoff,  118 
Tillaux,  amputation  of  forearm,  98 
of  membrana  tympani.  302 
catheterization     of      Eustachian 

tube,  304 
enucleation  of  eye,  290 
extirpation  of  lachrymal   gland, 

298 
gastrotomy,  339 
ligature  of  posterior  tibial  artery, 

88 
resection  of   superior    maxillary 
nerve,  214 
Toenail,  ingrown,  498 
Toes,  amputation  of,  107 
Tongue,  excision,  317 

by  ecrascur,  322 
Billroth,  820 
Kocher,  320 
Paget,  328 
Regnoli,  320 
S^dillot,  321 
temporary  ligature,  819 
Tonsils,  excision,  801 
Torsion  of  arteries,  80 
Tourniquet,  33 


43 


506 


INDEX 


Tracheotomy,  329 

by  thermo-cautery,  331 
Treatment  of  surgical  wounds,  35 
Trglat,  staphyloraphy  needle,  80S 

uranoplasty,  313 
Trephining,  207 

antrum,  210 

cranium,  207 

frontal  sinus,  210 
Trichiasis,  265 
Tubercle,  carotid,  62 

TTLNA,  excision,  198 

^      Ulnar  artery,  ligature,  69 

Umbilical  hernia,  radical  cure,  378 

strangulated,  365 
Uranoplasty,  312 

nasal  flap,  315 

osteoplastic,  315 
Ure,  tibio-tarsal  amputation,  120 
Urethra,  rupture  in  lithotomy,  441 
Urethral  fistulne,  411 
Urethroplasty,  408,  414 
Urethroraphy,  413 

Urethrotomy,  external  perineal,  with 
guide,  417 
without  guide,  419 

in  the  female,  450 

yACCA-BERLINGHIERT,  oesopha- 
'       geal  sound,  332 
Vagina,  narrowing  of,  469 
obliteration  of,  469 
prolapse  of  posterior  wall,  455 
with  laceration,  457 
Vaginae,  atresia,  453 
Vaginal  ovariotomy,  483 

hysterectomy,  484 
Van  Buren,  amputation  at  hip-joint, 
139 
hemorrhage     in     operations     on 

mouth,  306 
ligature  of  internal  iliac,  80 
salivary  fistula,  325 
tunnelled  instruments,  417 
Van  Buren  and  Keyes.  hydrocele,  392 
lateral  lithotomy,  438 
perineal  urethrotomy,  417 


Varicocele,  393 

Velpeau,  excision  of  rectum,  385 
of  scapula,  195 
ligature    of    innominate    arterv, 

57 
rhino[)lasty,  249 
Verneuil,     amputation     at    hip-joint, 
137 
excision  of  astragalus,  206 
frenum  of  penis,  402 
gastrostomy,  338 
imperforate  anus,  383 
plastic  operations,  222  * 

rhinoplasty,  245 
staphyloraphy,  305,  311 
uranoplasty,  312 
1  urethroraphy.  413 

Vertebral  artery,  ligature,  63 
'  Vesico- vaginal  fistula,  closure  of,  462 
creation  of,  468 
Vidal,  obliteration  of  vagina,  469 

varicocele,  394 
Voillemier,  puncture  of  bladder,  424 
Vogt,  excision,  143 

of  ankle.  175 
of  elbow,  154 
I  Volkmann,  excision  of  rectum,  386 
hydrocele,  393 

"ll,^ATSON,  excision  of  elbow,  156 
"       Web  fingers,  496 
I  Wecker,  iridotomy,  271 
Wells,  iridesis,  277 

solution  of  cataract,  281 
suction  of  cataract,  291 
Wells,     Spencer,    emptying    ovarian 
cysts,  478 
suture  in  hysterotomy,  485 
Wood,  radical  cure  of  femoral  hernia, 
376 
of  inguinal  hernia,  367 
of  umbilical  hernia,  378 
Wounds,  treatment  of  surgical,  35 
Wrist,  amputation  at,  97 
excision,  156 
Lister,  159 
Oilier,  162 
Von  Langenbeck,  163 


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"DARKER  (FORDYCE.)     OBSTETRICAL  AND  CLINICAL  ESSAYS. 

In  one  handsome  12mo.  volume  of  about  300  pages.     Preparing. 
■pARLOW    (GEORGE    H.)     A   MANUAL  OF   THE  PRACTICE   OF 
^     MEDICINE.     In  one  Svo.  volume  of  603  pages.     Cloth,  $2  50. 
"DARNES  ^FANCOURT).    A  MANUAL  OF  MIDWIFERY  FOR  MID- 
^     WIVES.    In  one  12mo.  vol.  of  197  pp.,  with  50  illus.  Cloth,  $1  25. 
DARNES    (ROBERT).    A  PRACTICAL  TREATISE  ON   THE  DIS- 
^     EASES  OF  WOMEN.    Third  American  from  3dEnglish  edition.  In 

one  Svo.  vol.  of  about  800  pages,  with  about  200  illus.  Preparing. 
■pARNES  (ROBERT  and  FAN  COURT).  A  SYSTEM  OF  OBSTET- 
^  RIC  MEDICINE  AND  SURGERY,  THEORETICAL  AND  CLIN- 
ICAL. The  Section  on  Embryology  by  Prof.  Milnes  Marshall. 
In  one  large  octavo  volume  of  872  pages,  with  231  illustrations. 
Cloth,  ^b\  leather,  $6.     Just  ready. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 


TDARTHOLOW  (ROBERTS).     MEDICAL  ELECTRICITY.    A  PRAC- 

•^     TICAL  TREATISE  ON  THE  APPLICATIONSOF  ELECTRICITY 

TO   MEDICINE  AND  SURGERY.     Second  edition.     In  one  8vo. 

volume  of  2<.)2  p.nges,  with  101»  illustrations.      Cloth,  $2  50. 

■pASHAM  (W.  R.)     RENAL  DISEASES  ;  A  CLINICAL  GUIDE  TO 

"^     THEIR  DIAGNOSIS  AND  TREATMENT.    In  one  12mo.  volume 

of  30-i  p.iges,  with  illustrations.     Cloth,  $2  00. 

TjELLAMY  (EDWARD).  A  MANUAL  OF  SURGICAL  ANATOMY. 
In  one  12mo.vol.  of  300  pages,  with  50  illustrations.  Cloth,  .$2  25. 

OPERATIVE  SURGERY.     In  press.    See  Students'  Series  of  Ma7i- 

nals,  p.  14. 

"DELL  (F.  JEFFREY).  COMPARATIVE  PHYSIOLOGY  AND  ANAT- 
OMY. In  one  12ino.  volume  of  561  pages,  with  229  woodcuts. 
Cloth,  $2.     Just  ready.      See  Students'  Series  of  Mannals,  p.  14. 

■pLOXAM  (C.  L.)  CHEMISTRY,  INORGANIC  AND  ORGANIC. 
With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  727  pages,  with  292  illustra- 
tions.   Cloth,  $3  75;  leather,  $4  75. 

■pRISTOWE  (JOHN  SYER).  A  TREATISE  ON  THE  PRACTICE  OF 
MEDICINE.  Second  American  edition,  revised  by  the  Author. 
Edited  with  additions  by  James  II.  Hutchinson,  M.D.  In  one 
8vo.  vol.  of  1085  pp.     Cloth,  $5:  leather,  $6;  half  Russia.  $6  50. 

TDROADBENT,  (W.  H.)  THE  PULSE.  Preparing.  See  Series  of 
Clinical  Maiinals,  p.  13. 

■pROWNE  (EDGAR  A.)  HOW  TO  USE  THE  OPHTHALMOSCOPE. 
Elementary  instruction  in  Ophthalmoscopy  for  the  Use  of  Students. 
In  one  emnlll2mo.  volume  of  1 16  pages,  with  35  illust.    Cloth,  $1. 

■pROWNE  (LENNOX).  THE  THROAT  AND  ITS  DISEASES.  New 
edition.  In  one  handsome  imperial  8vo.  volume,  with  12  colored 
plates,  120  typical  illust.  in  color  and  50  woodcuts.    Preparitig. 

■pRUCE    (J.    MITCHELL).      MATERIA    MEDIC  A    AND   THERA- 

■^  PEUTICS.  In  one  ]2mo.  volume  of  555  pages.  Cloth,  $1  50. 
See  Stndents'  Series  of  Manuals,  p.  14. 

■pRUNTON    (T.   LAUDER).      A   MANUAL    OF    PHARMACOLOGY, 

■^  THERAPEUTICS  AND  MATERIA  MEDICA  ;  including  the 
Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of 
Drugs.  In  one  octavo  volume  of  1033  pages,  with  188  illustrations. 
Cloth,  $5  50;  leather,  $6  50.  Just  ready. 
RYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth 
American  from  the  fourth  English  edition.  In  one  imperial  octavo 
volume  of  1040  pages,  with  727  illustrations.  Cloth,  $6  60; 
leather,  §7  50  ;  half  Russia,  $8  00. 

DRY  ANT  (THOMAS).  DISEASES  OF  THE  BREAST.  Preparing. 
See  Series  of  Clinical  Manuals,  p.  13. 

■pUMSTEAD  (F.  J.)   and  TAYLOR  (R  W.)  THE  PATHOLOGY  AND 

■^  TREATMENT  OF  VENEREAL  DISEASES.  Fifth  edition,  re- 
vised and  rewritten,  with  many  additions,  by  R.  W.  Taylor,  M.D. 
In  one  handsome  8vo.  vol.  of  898  pages,  with  139  illustrations,  and 
two  chromo-lithographic  plates  containing  13  figures.  Cloth,  $4  75; 
leather,  $5  75  ;  very  handsome  half  Russia,  $6  25. 

AND CULLERIER'S  ATLAS  OF  VENEREAL. See  "CuLLEuiEK." 


B 


4  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

-pTJENZTT  (CHARLES  H.)    THE  EAR  :   ITS  ANATOMY,  PHY^- 
^     OLOaY  AND  DISEASES.     A  Practical  Treatise  for  the  Use  of 
Students  and  Practitioners.     New  edition.    In  one  8vo.  vol.  of  680 
pages,  with  107  illustrations.     Cloth,  $4;  leather.  $5. 
■pUTLIN,  (HENRY  T.)      DISEASES   OF   THE    TONGUE.      In  one 
pocket-size  12mo.  vol.  of  456  pp.,  with  8  col.  plates  and  3  woodcuts. 
Limpcloth,  $.3  50.    Jtistready.   See  Series  of  Clinical  Manuals,  p.  13. 
pARPEKTER    WM.  B  )     PRIZE  ESSAY  ON  THE  USE  OF  ALCO- 
^     IIOLIC  LIQUORS  IN  HEALTH  AND  DISEASE.     New  Edition, 
with  a  Preface  by  D.  F.  Condie,  M.D.     One  12mo.  volume  of  178 
pages.    Cloth,  60  cents. 
pARPENTER  (WM.  B.)    PRINCIPLES  OF  HUMAN  PHYSIOLOGY. 
A  new  American,  from  the  eighth  English  edition.     In  one  large 
8vo.  volume  of  1083  pages,  with  373  illustrations.     Cloth,  $5  50; 
leather,  raised  bands,  $6   50  ;  half  Russia,  raised  bands,  $7. 
pENTURY  OF  AMERICAN  MEDICINE.— A  History  of  Medicine  in 
^     America,  1776-1S76.   In  one  12mo.  vol.  of  366  pages.  Cloth, $225. 
CHAMBERS  (T.  K.)      A  MANUAL  OF  DIET  IN  HEALTH   AND 
DISEASE.    In  one  handsome  Svo.  vol.  of  302  pages.    Cloth,  $2  75. 
pHARLES     (T.    CRANSTOUN).      THE    ELEMENTS    OF    PHYSIO- 
^     LOGICAL  AND  PATHOLOGICAL  CHEMISTRY.     In  one  hand- 
some octavo  volume  of  451  pages,  with  38  woodcuts  and  one  colored 
plate.    Cloth,  3  50. 
pHURCHILL    (FLEETWOOD).     ESSAYS   ON    THE   PUERPERAL 
^     FEVER.    In  one  octavo  volume  of  464  pages.    Cloth,  $2  50. 
pLAREE  (W.  B.)   AND  LOCKWOOD    (C.  B)      THE  DISSECTOR'S 
MANUAL.    In  one  12mo.  volume  of  396  pages,  with  49  iUustrations. 
Cloth,  $1  50.      See  Students^  Series  of  Maatials,  p.  14. 
pLASSEN'S  QUANTITATIVE  ANALYSIS.    Translated  by  Edgar  F. 
^     Smith,  Ph.D.  Inone  12mo.  vol.  of  324pp..  with36  illus.  Cloth.  $2  00. 
pLELANL  (JOHK).    A  DIRECTORY  FOR  THE  DISSECTION  OP 
^     THE  HUMAN  BODY.    In  one  12mo.  vol.  of  178  pp.    Cloth,  $125. 
pLOUSTON  (THOMAS  S.)     CLINICAL   LECTURES    ON   MENTAL 
^     DISEASES.    TTith  an  Abstract  of  Laws  of  U.  S.  on  Custody  of  the 
Insane,  by  C.  F.  Fo  som,  M.D.     In  one  handsome  octavo  vol.  of  541 
pages,  illustrated  with  woodcuts  and  S  lithographic  plates.      Cloth, 
$4  00.     Dr.  Folsom's  Abstract  is  also  furnished  separately  in  one 
octavo  volume  of  108  pages.     Cloth,  $1  50. 
pLOWES  (FRANK).    AN  ELEMENTARY  TREATISE  ON  PRAC- 
^     TICAL      CHEMISTRY     AND     QUALITATIVE     INORGANIC 
ANALYSIS.     New  American  from  the  fourth  English  edition.     In 
one  handsome  12mo.  volume  of  387   pages,   with  55    illustrations. 
Cloth,  S2  50.     Just  ready. 
pOATS  (JOSEPH),    A  TREATISE  ON  PATHOLOGY.     In  one  vol.  of 
^     S29  pp. ,  with  339  engravings.     Cloth,  $5  50  ;  leather,  $6  50. 
pOHEN  (J.  SOLIS).      DISEASES  OF  THE  THROAT  AND  NASAL 
PASSAGES.     Third  edition,  thoroughly  revised.      In  one  handsome 
octavo  volume.     Frej^aring. 
pOLEMAN  (ALFRED).    A  MANUAL  OF  DENTAL  SURGERY  AND 
^     PATHOLOGY.     With  Notes  and  Additions  to  adapt  it  to  American 
Practice.  By  Thos.  C.  Scellwagen,  x*I.A.,  M.D.,  D.D.S.  In  one  hand- 
some Svo.  vol.  of  412  pp.,  with  331  illus.    Cloth,  $3  25. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  5 

HDNDIE  (D.FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES  OF  CHILDREN.  Sixth  edition,  revised  and  enl.irged.  In 
one  large  8vo.  vol.  of  719  pages.     Cloth,  $5  25  ;  leather,  SO  25. 

pOOPER(B.B.)  LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  SUR(iERY.    InonehirgeSvo.  vol.  of  767  pages.    Cioth.  #2  00. 

pORNIL  (V.),  AND  RANVIER  (L.)    xMANUAL  OF  PATHOLOOICAL 

^  HISTOLOGY.  Translated,  with  Notes  and  Additions,  by  E.  0. 
Shakespeare,  M.D.,  and  J.  Henry  C.  Simes,  M.D.  In  one  octavo 
volume  of  800  pages,  with  .300  illustrations.  Cloth,  S5  50  ;  leather, 
$0  50;   very  handsome  half  Russia,  raised  bauds,  $7 

nORNIL  (V.)  SYPHILIS  :  ITS  MORBID  ANATOMY,  DIAGNOSIS 
AND  TREATMENT.  Translated,  with  notes  and  additions,  by  J. 
Henry  C.  Simes,  M.D  ,  and  J.  William  White,  M.D.  In  one  Svo. 
volume  of  461  pages,  witli  84  illustrations.     Cloth,  $.3  75. 

pULLERIER  (A.)  AN  ATLAS  OF  VENEREAL  DISEASES.  Trans- 
lated and  edited  byFuEEMAN  J.  Bumsteab,  M.D.,  LL.D.  A  large 
quarto  volume  of  328  pages,  with  26  plates  containing  about  150 
figures,  beautifully  colored,  many  of  them  life-size.     Cloth,  $17. 

nUENOW  (JOHN).  M  DICAL  APPLIED  ANATOMY,  hi  press. 
See  St?(r/ent^s  Series  of  Manuals,  p.  14. 

TjALTON  (JOHN  C.)  DOCTRINES  OF  THE  CIRCULATION  OF 
THE  BLOOD.  In  one  handsome  12mo.  volume  of  293  pages.  Cloth, 
$2.     Just  ready. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.     Seventh  edition, 

thoroughly  revised,  and  greatly  improved.  In  one  very  handsome 
Svo.  vol.  of  722  pages,  with  252  illustrations.  Cloth,  $5;  lea- 
ther, $6;  very  handsome  half  Russia,  $6  50. 

T) ANA  (JAMES  D.)  THE  STRUCTURE  AND  CLASSIFICATION  OF 
ZOOPHYTES.    Withillust.onwood.  Inoneimp.4to.  vol.    CI. ,$4. 

TjAVIS  (F.  H.)  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition     In  one  12mo.  volume  of  287  pages.     Cloth,  $175. 

T|E  LA  BECHE'S  GEOLOGICAL  OBSERVER.   In  one  large  Svo.  vol. 

•^    of  700  pages,  with300illustrations.    Cloth,  $4. 

TJRAPER  (JOHN  C.)  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  vol- 
ume of  734  pages,  with  376  illustrations.     Cloth,  $4.     Just  ready. 

TjRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MOD- 

•^  ERN  SURGERY.  From  the  8th  London  edition.  In  one  octavo 
volume  of  687  pages,  with  432  illus.     Cloth,  $4;  leather,  $5. 

TJUNCAN  (J.MATTHEWS).    CLINICAL  LECTURES  ON  THE  DIS- 

^  EASES  OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.    Cloth,  $1  50. 

TJUNGLISON  (ROBLEY).    MEDICAL  LEXICON;     A  Dictionary  of 

Medical  Science.     Containing  a  concise  explanation  of  the  variou.s 

subjects  and  terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 

Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medi- 

calJurisprudenceand  Dentistry;  notices  of  Climate  and  of  Mineral 

Waters  ;  Formulae  forOfficinal,  Empirical  and  Dietetic  Preparations; 

with  the  accentuation  and  Etymology  of  the  Terms,  and  the  French 

and  other  Synonymes.     Edited  by  R.  J.  Dunglison,  M.D.     In  one 

very  large  royal  Svo.  vol.  of  1139  pages.      Cloth,  $6  50  ;  leather, 

$7  50;  half  Russia,  $8. 


6  LEA  BROTHERS  &  CO.'S  PUBLICATIO>'S. 

pDIS  (ARTHUR  W.)  DISEASES  OF  WOMEN.  A  Manual  for  Stu- 
dents  and  Practitioners.  In  one  hnndsome  8vo.  vol.  of  576  pp., 
with  148  illustrations.     Cloth,  $3;  leather,  $4. 

■PLLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY. 
Being  a  Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection. 
Fromtheeighth  and  revised  English  edition.  In  one  octavo  vol.  of 
716  pages,  with  249  illustrations.     Cloth.  $4  25  ;  leather,  $5  25. 

pMMET  (THOMAS  ADDIS).     THE  PRINCIPLES  AND  PRACTICE 

■^  OF  GYNAECOLOGY,  for  the  use  of  Students  and  Practitioners. 
New  (third)  edition,  enlarged  and  revised.  In  one  large  Svo. 
volume  of  880  pages,  with  150  original  illustrations.  Cloth,  $5; 
leather,  $6  ;   half  Russia,  $6  50.     Just  ready. 

■pRICHSEN  (JOHN  E.)  THE  SCIENCE  AND  ART  OF  SURGERY. 
A  new  American,  from  the  eighth  enlarged  and  revised  London 
edition.  In  two  large  octavo  volumes  containing  2316  pages,  with 
984  illustrations.  Cloth,  S9 ;  leather,  $11:  half  Russia,  raised 
bands,  $12.     Just  ready. 

■pSMARCH  (FRIEDRICH).  EARLY  AID  IN  INJURIES  AND 
ACCIDENTS.  In  one  small  12mo.  volume  of  109  pages,  with  24 
illustrations.     Cloth,  75  cents. 

pAEQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Third  American  edition,  specially  revised  by  the  Author.  Edited, 
withadditions,embracingthe  U.  S.  Pharmacopoeia,  by  Frank  Wood- 
bury, M.D.     In  one  12mo.  volume  of  524  pages.     Cloth,  $2  25. 

PSNWICK  (SAMUEL).     THE  STUDENTS'  GUIDE  TO  MEDICAL 

"^  DIAGNOSIS.  From  the  third  revised  and  enlarged  London  edi 
tion.    In  one  royal  12mo.  volume  of  328  pages.    Cloth,  $2  25. 

"piNLAYSON  (JAMES).  CLINICAL  DIAGNOSIS.  A  Handbook  for 
Students  and  Practitioners  of  Medicine.  In  one  handsome  Svo. 
vol.  of  546  pages,  with  85  woodcuts.     Cloth,  $2  63. 

pLINT    (AUSTIN).    A    TREATISE  ON  THE  PRINCIPLES    AND 

■^  PRACTICE  OF  MEDICINE.  Fifth  edition,  revised  and  largely 
rewritten.  With  an  Appendix  on  the  Researches  of  Koch  and  their 
Bearing  on  the  Etiology,  Pathology,  Diagnosis  and  Treatment  of 
Pulmonary  Phthisis.  In  one  large  Svo.  vol.  of  1160  pages  Cloth, 
$5  50;  leather,  $6  50  ;  very  handsome  half  Russia,  $7. 

A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION  ;  of  the 

Physical  Diagnosisof  Diseases  of  the  Lungs  and  Heart,  arad  of  Tho- 
racic Aneurism.  New  (fourth)  edition,  revisedand  enlarged.  In  one 
handsome  12mo.  volume  of  240  pages.     Cloth,  $1  G3.     Just  ready. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  HEART.  Second  edition, enlarged. 
In  one  octavo  volume  of  550  pages.     Cloth,  $4  00. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RESPIRATORY  ORGANS.  Second  and  revised 
edition.     In  one  octavo  volume  of  591  pages.     Cloth,  $4  50. 

CLINICAL  MEDICINE.     A   SYSTEMATIC    TREATISE  ON 

THE  DIAGNOSIS  AND  TREATMENT  OF  DISEASE.  Designed 
for  Students  and  Practitioners  of  Medicine.  In  one  handsome  octavo 
vol.  of  799  pages.     Cloth,  $4  50  ;  leather,  $5  50  ;  halfRussia,$6  00. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  7 

pLINT  (AUSTIN).    MEDICAL  ESSAYS.    In  one  12rao.  vol.,  pp.  210. 

■*"      Cloth,  $1  '^^. 

0>^  PHTinsrS:  IT.S  MORBID  ANATOMY,  ETIOLOOY,  etc., 

a  series  of  Clinical  Lectures.     In  one  8vo.  volume  of  442  pages. 

Cloth.  $.3  50. 
THE    PHYSICAL    EXPLORATION    OF    THE    LUNGS,    BY 


MEANS    OF    AUSCULTATION    AND    PERCUSSION.      In    one 
small  12mo.  volume  of  83  pages.     Cloth,  $1. 

pOLSOM  (C.  F.)     An  Abstract  of  Stitutes  of  U.  S.  on  Custody  of  the 

■'•  Insane.  In  one  Svo.  vol.  of  108  pp.  Cloth,  $1  50.  Also  bound 
with  CloiU'toti  0)1  Insanity. 

pOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  New 
(third)  American  from  the  fourth  English  edition,  edited  by  E.  T. 
Reichert,  M.D.  In  on^  large  12mo.  vol.  of  90S  pages,  with  271 
illustrations.     Cloth,  $.3  25;  leather,  .$3  75.     Just  ready. 

A  TEXT-BOOK  OF  PHYSIOLOGY.    English  Student's  edition. 

In  one  12mo.  volume  of  804 pages,  with  72  illustrations.    Cloth,  $3. 

pDTHERGILL'SPRACTITIONER'SUANDBOOKOF  TREATMENT. 
New  edition.      In   one  handsome  octavo  vol.   of  about   650   pp. 
Preparing. 

pOWNES  (GEORGE) .  A  MANUAL  OF  ELEMENT  ARYCHEMISTRY. 
New  edition.  Embodying  Watts'  Physical  and  Inorganic  Chem- 
istry. In  one  royal  12mo.vol.  of  1061  pp.,  with  168  illus.,  and 
one  colored  plate.     Cloth,  $2  75;  leather,  $3  25.     Just  ready. 

pox  (TILBURY)  and  T.  COLCOTT.  EPITOME  OF  SKIN  DIS- 
EASES, with  Formulae.  For  Students  and  Practitioners.  Third 
Am.  edition,  revised  by  T.  C.  Fox.  In  one  small  12mo.  volume 
of  238  pages.     Cloth,  $1  25. 

pRfl^NKLAND  (E.)  and  JAPP  (F.  R.)  INORGANIC  CHEMISTRY. 
In  one  handsome  octavo  vol.  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3  75;  leather,  S4  75.     Just  ready . 

pULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.   From2dEng.ed     In  I  Svo.  vol.,  pp.  475.   Cloth, $3  50. 

niBNEY  (V.  P.)  ORTHOPEDIC  SURGERY.  For  the  use  of  Prac- 
titioners and  Students.     In  one  8vo-  vol.  profusely  illus.     Prepg. 

niBSON'S  INSTITUTES  AND  PRACTICE  OF  SURGERY.  In  two 
octavo  volumes  of  965  pages,  with  34  plates.     Leather,  $6  50. 

pLUGE  (GOTTLIEB).  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated  by  Joseph  Leidy,  M.D.,  Professor  of  Anatomy  in  the 
University  of  Pennsylvania,  «fec.  In  one  imperial  quarto  volume, 
with  320  copperplate  figures,  plain  and  colored.    Cloth,  $4. 

nOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo. 
vol.  of  589  pages.  Cloth,  $2.  See  Students^  Series  of  Mamials,  p.  14. 
RAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
Edited  by  T.  Pickering  Pick,  F.R.C.S.  A  new  American,  from  the 
tenth  and  enlarged  London  edition.  To  which  is  added  Holden's 
•'Landmarks,  Medical  and  Surgical,"  with  additions  by  ^V.  W. 
Keen,  M.D.  In  one  imperial  octavo  volume  of  1023  pages,  with 
664  large  and  elaborate  engravings  on  wood.  Cloth,  $6  :  leather, 
$7  ;  very  handsome  half  Russia,  raised  bands,  $7  50. 


G 


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OCHAFER    (EDWARD    A.)      THE    ESSENTIALS  OF   HISTOLOGY, 
•^     DESCRIPTIVE  AND  PRACTICAL.     For  the  use  of  Students.     In 
one  handsome  octavo  volume  of  246  pages,  with  281  illustrations. 
Cloth,  $2  25.     Just  ready. 
aCHMITZ    AND    ZUMPT'S   CLASSICAL  SERIES.    In  royal  18mo. 
•^     ADVANCED  LATIN  EXERCISE.?.    Cloth,  60  cents  ;  half  bound, 
70  cents. 
SALLUST.     Cloth,  eOcents:  half  bound,  70  cents. 
NEPOS.     Cloth,  60  cents:  half  bound,  70  cts. 
VIR(tIL.     Cloth,  85  cents:  half  bound,  $1. 
CURTIUS.     Cloth,  80  cents;  half  bound,  90  cents. 

OCHOEDLER  (FREDERICK)  AND  MEDLOCK  (HENRY) .  WONDERS 
OF    NATURE.     An    elementary   introduction  to    the  Sciences   of 
Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology ,  Botany,  Zool- 
ogy and  Physiology.    In  one  8vo.  vol.,  with  679  illus.    Cloth,  $3. 
nCHREIBER  (JOSEPH).     A  MANUAL  OF  TREATMENT  BY  MAS- 
*^     SACtE  and  METHODICAL   MUSCLE  EXERCISE.      Translated 
by  Walter  Mendelson,  M.D.     In  one  octavo  volume  of  about  30C 
pages,  with  about  125  engravings.     Preparing. 
nEILER  (CARL).     A  HANDBOOK  OF  DIAGNOSIS  AND  TREAT- 
"      MENT  OF  DISEASES  OF  THE  THROAT  AND  NASAL  CAV- 
ITIES.    Second  edition.     In  one  very  handsome  12aio.  volume  of 
294  pages,  with  77  illustrations.     Cloth,  $1  75. 
nERIES  OF  CLINICAL  MANUALS.     A  series  of  authoritative  mono- 
graphs  on  important  clinical  subjects,  in  12mo.  volumes  of  about  550 
pages,  well  illustrated.    The  following  volumes  are  just  ready  :  Butlin 
on  the  Tongue  (cloth,  $3  50) ;  Savage  on  Insanity  and  Allied  Neuroses 
(cloth,  $2  00),  and  Treves  on  Intestinal  Obstruction   (cloth,  $2  00). 
The  following  will  be  ready  shortly  :   Morris  on  Surgical  Diseases  of 
the  Kidney  ;  Owen  on  Surgical  Diseases  of  Children,  and   Pick  on 
Fractures  and  Dislocations.    The  following  are  in  press  :  Hutchinson 
on  Syphilis  ;   Bryant  on  the  Breast ;   Broadbent  on  the  Pulse  ;   Lucas 
on  Diseases  of  the  Urethra  ;    Marsh  on  Diseases  of  the  Joints;  Ball 
on  the  Rectum  and  Anus. 
For  separate  notices,  see  under  various  authors'  names. 
qlMON  (W.)      MANUAL   OF  CHEMISTRY.     A  Guide  to  Lectures 
and  Laboratory  work  for  Beginners  in   Chemistry.     A  Text-book 
specially  adapted  for  Students  of  Pharmacy  and  Medicine.     In  one 
8vo.  volume  of  410  pages,  with  16  woodcuts  and  7  plates,  largely 
of  actual  deposits.     Cloth,  $3  00.     Also  without  plates,  §2  50. 


M  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 


OKEY  iPREDERIC  C.)    OPERATIVE  SURGERY     In  one  8vo.  vol. 
of  661  pages,  with  81  woodcuts.     Cloth,  §3  25. 

nLADE(D.D.)   DIPHTHERIA;  ITS  NATURE  AND  TREATMENT- 
'-econd  edition.     In  one  rojal  12mo.  vol.  pp.  158.     Cloth,  SI  25. 
MiTH   (EDWARD).    CONSUMPTION;   ITS  EARLY  AND  REME- 
DIABLE STAGES.     In  one  8vo.  vol.  of  253  pp.     Cloth,. $2  25. 
MITH  (HENRY  H.)  AND  HORNER  (WILLIAM  E.)   ANATOMICAL 
ATLAS.    Illustrative  of  the  structure  of  the  Human  Body.    In  one 
large  imperial  8  vo.  vol.,  with  about  650  be.outiful  figures.  Clo.,  $4  50. 
OMITH  (J.LEWIS).     A  TREATISE  ON  THE  DISEASES  OF  IN- 
*^     FANCY  AND  CHILDHOOD.     New  (sixth)   edition,  revised  and 
enlarged.     In  one  large   Svo.  volume  of  about   850  pages,  with 
illustrations.     Shortly. 
OTILIE  (ALFRED).      CHOLERA.  ITS  ORIGIN,  HISTORY,  CAUSA- 
'^     TION,    SYMPTOMS,    LESIONS,    PREVENTION    AND    TREAT- 
MENT.    In  one  handsome  12rao.  volume  of  163  pages,  with  a  chart 
showing  routes  of  previous  epidemics.     Cloth,  $1  25.     Just  rt^ady. 
miLLE  (ALFRED).     THERAPEUTICS  AND  MATERIA  MEDIC  A. 
Fourth  revised  edition.     In  two  handsome  octavo  volumes  of  1936 
pages.    Cloth, $10;  leather. $12;  very  handsome  half  Russia.  .S13. 
OTILLE    (ALFRED)  AND  MAISCH  (JOHN  M.)     THE  NATIONAL 
*^     DISPENSATORY:     Containing  the  Natural  History,  Chemistry, 
Pharmacy.  Actions  and  Uses  of  Medicines.     Including  those  rec- 
ognized in  the  Pharmacopoeias  of  the  United  States,  Great  Britain 
and    Germany,   with  numerous  references  to  the  French  Codex. 
Third  edition,  thoroughly  revised  and  greatly  enlarged.     In  one 
magnificent  imperial  octavo  volume  of  1767  pages,  with  31]  accu- 
rate engravings  on  wood.     Cloth,  $7  25  ;  leather,  raised  bands,  $8  ; 
very  handsome  half  Russia,  raised  bands  and  open  back.  $9.     Also, 
furnished  with  Ready  Reference  Thumb  letter  Index  for  $1  in  addi- 
tion to  price  in  any  of  the  above  styles  of  binding. 
OTIMSON  (LEWIS  A.)      A    PRACTICAL   TREATISE    ON   FRAC- 
^     TURES.     In  one  handsome  octavo  volume  of  584  pages,  with  360 
beautiful  illustrations.    Cloth,  S^4  75  ;  leather,  $5  75. 

A  MANUAL  OF  OPERATIVE  SURGERY.     New  edition.     In 

one  royal  12mo  volume  of  about  500  pages,  with  about  350  illus- 
trations. Cloth,  $2  50.  Shortly 
nTTJDENTS'  SERIES  OF  MANUALS.  A  series  of  fifteen  Manuals  by 
eminent  teachers  or  examiners.  The  volumes  will  be  pocket-size 
j2mos.  of  from  300-540  pages,  profusely  illustrated,  and  bound  in 
red  limp  cloth.  The  following  volumes  may  now  be  announced  : 
Bell's  Comparative  Physiology  and  Anatomy,  $2  00;  Robertson's 
Physiological  Physics,  $2  00;  Goulds  Sur-gical  Dingnosis,  $2  00; 
Klein's  Elements  of  Histology,  $150;  Pepper's  Surgical  Pathology, 
$2  00  ;  Treves'  Surgical  Applied  Anatomy,  $2  00  ;  Power's  Human 
Physiology,  $1  50;  Ralfe's  Clinical  Chemistry,  $1  50;  Clarke  and 
Lockwood"s  Dissector's  Manual,  $1  50  ;  and  Bruce's  Materia  Medica 
and  Therapeutics,  $1  b^,  just  ready.  The  following  volumes  are  in 
press  :  Bellamy's  Operative  Surgery,  Pepper's  Forensic  Medicine, 
and  Curnow's  Medical  Applied  Anatomy. 
For  separate  notices,  see  under  various  authors'  names. 


LEA  BROTHERS  k  CO.'S  PUBLICATIONS.  15 


OTOKES    (W.)     LECTURES    ON    FEVER.     In  one  8vo.   volume. 
^     Cloth,  $2. 

OTURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MKDICINK.  In  one  12nio.  vol.  Cloth,  $1  25. 
ANNER  (THOMAS  HAWKES).  A  MANUAL  OF  CLINICAL  MEDl. 
CINE  AND  PHYSICAL  DIAGNOSIS.  Third  American  from  the 
second  revised  English  edition.  Edited  by  Tilbury  Fox,  M.  D.  In 
one  handsome  12nio.  volume  of  302  pp.,  with  ill  us.  Cloth,  $1  50. 
ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    From 


T 


the  second  English  edition.  In  one  8vo.  volume  of  490  pages,  with 
four  colored  plates  and  numerous  woodcuts.     Cloth,  $4  25. 

mAYLOR  (ALFRED  S.)  MEDICAL  JURISPRUDENCE.  Eighth 
American  from  tenth  English  edition,  specially  revised  by  the 
Author.  Edited  by  John  J.  Reese,  M.D.  In  one  large  octavo 
volume  of  937  pages,  witfi  70  illustrations.  Cloth,  $5;  leather, 
$fl  ;  very  handsome  half  Russia,  raised  bands,  $6  50. 

ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDICAL 

JURISPRUDENCE.  Third  American  from  the  third  London  edi- 
tion. In  one  octavo  volume  of  788  pages,  with  104  illustrations. 
Cloth,  $5  50  ;  leather,  $6  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURIS- 


PRUDENCE.    Third  ed .    In  two  handsome  8vo.  vols,  of  141G  pp., 
with  188  illustrations.     Cloth,  $10;  leather,  $12. 

rpHOMAS  (T.  GAILLARD) .    A  PRACTICAL  TREATISE  ON  THE 
"*■     DISEASES  OF   WOMEN.    Fifth  edition,  thoroughly  revised  an 
rewritten.    In  onelarge  and  handsome  octavo  volume  of  810  pages, 
with  266  illustrations.    Cloth,  $5  ;  leather,  $6  ;  very  handsome  half 
Russia,  $6  50. 

rnHOMPSON  (SIR HENRY).   CLINICAL  LECTURES  ON  DISEASES 
■*•     OF  THE  URINARY  ORGANS.     Second  and  revised  edition.    In 
one  octavo  volume  of  203  pages,  with  illustrations.    Cloth,  $2  26. 

rpHOMPSON    (SIR   HENRY).     THE    PATHOLOGY  AND  TREAT- 
•*-      MENT  OF  STRICTURE  OF  THE  URETHRA  AND  URINARY 
FISTULA.     From  the  third  English  edition.     In  one  octavo  vol. 
ume  of  359  pages,  with  illustrations.     Cloth,  $3  50. 

miDY    (CHARLES  MEYMOTT) .     LEGAL  MEDICINE.     Volumes  I 
and  II.     Two  imperial  octavo  volumes  containing  1193  pages,  with 
2  colored  plates.     Per  volume,  cloth,  $6;   leather,  $7. 

rpODD  (ROBERT  BENTLEY).   CLINICALLECTURES  ON  CERTAIN 
•*•     ACUTE  DISEASES.    In  one8vo.  vol.  of  320  pp.,  cloth,  $2  50. 
rriREVES   (F.)      SURGICAL   APPLIED    ANATOMY.     In  one  12mo. 

volume  of  540  pages,  with  61  illustrations.      Cloth,    ^2  00.      See 

Students^  Series  of  Mamials,  page  14. 
ryiREVES  (FREDERICK).     INTESTINAL   OBSTRUCTION.     In  one 

12mo.  volume  of  522  pages,  with  60  illustrations.     Cloth,  $2.    Just 

ready.     See  Series  of  Clinical  Manuals,  p.  13. 
rpUKE  (DANIEL  HACK).   THE  INFLUENCE  OF  THE  MINDUP^N 

THE  BODY.  New  edition.    In  onehandsome  8vo.  vol.  of  467  pages, 

with  2  colored  plates.     Cloth,  $3. 


3  6  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

YISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1886. 
Accommodates  record  of  practice  of  30  patients  per  day.  Hand- 
somely bound  in  limp  morocco,  wallet  form,  with  tuck  and  pencil, 
$1.  To  advance  paying  subscribers  to  The  Medical  News,  75  cents. 
WALSHE  (W.  H.)  PRACTICAL  TREATISE  ON  THE  DISEASES 
'"  OFTHEHEART  AND  GREAT  VESSELS.  3d  American  from  the 
3d  revised  London  edition.   In  one  Svo.  vol.  of420  pages.  Cloth,  $3^ 

WATSON    (THOMAS).    LECTURES  ON  THE  PRINCIPLES  AND 
''    PRACTICE  OF  PHYSIC.    A  new  American  from  the  fifth  and  en- 
larged English  edition,  with  additions  by  H.  Hartshorne,  M.D.    In 
two  largeSvo.  vols,  of  1840  pp.,  with  190  cuts.    Clo.,$9;  lea.,  $11. 

WELLS  (J.  SOELBERG).  A  TREATISE  ON  THE  DISEASES  OF 
'  THE  EYE.  Fourth  edition,  thoroughly  revised  by  Chas.  S.  Bull, 
A.M.,  M.D.  In  one  large  and  handsome  octavo  vol.  of  822  pages, 
with  6  colored  plates  and  257  woodcuts,  as  well  as  selections  from 
the  test-types  of  Jaeger  and  Snellen.  Cloth,  $5  ;  leather,  $6  ;  very 
handsome  half  Russia,  $6  50. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  third  English  edition.  In 
one  octavo  volume  of  543  pages.  Cloth,  $3  75  ;  leather,  $4  75. 
,  LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILD- 
HOOD. Fifth  American  from  the  sixth  revised  English  edition.  In 
one  large  Svo.  vol.  of  686  pages.     Cloth,  $4  50  ;  leather,  $5  50. 

. ON  SOME  DISORDERS   OF    THE    NERVOUS  SYSTEM   IN 

CHILDHOOD.     In  one  small  12mo.  vol.  of  127  pages.     Cloth,  $1. 

WILLIAMS  (CHARLES  J.  B.  and  C.  T.)  PULMONARY  CONSUMP- 
TION :  ITS  NATURE,  VARIETIES  AND  TREATMENT.  In 
one  octavo  volume  of  303  pages.     Cloth,  $2  50. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  A 
new  andrevised  American  fromthelastEnglish  edition.  Illustrated 
with  397  engravings  on  wood.  In  one  handsome  octavo  volume 
of  616  pages.    Cloth,  $4  ;  leather,  $5. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.     In 

one  handsome  royal  12mo.  vol.     Cloth,  $3  50. 
WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
''   With  additions  by  the  Author.    Translated  by  James  R.  Chadwick, 
A.M. ,  M.D.    In  one  handsome  Svo.  vol.  of  484  pages.    Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  8th  German  edition,  by  Ira  Remsen,  M.D.  In  one  12m'^. 
volume  of  550  pages.    Cloth,  $3  00. 

WOODHEAD  (G.  SIMS).  PRACTICAL  PATHOLOGY.  A  manunl 
for  Students  and  Practitioners.  In  one  beautiful  octavo  vol.  of  4^7 
pages,  with  136  exquisitely  colored  iH^-  Cloth, ^$6. 
■yE^P-BGOK  OF  TREATMENT  ^OR  l8^.  A  dfoifiiDr^h^nsive  and 
**•  Critical  Review  for  Practitioners  ((f  Medi(flfieTHfn  contributions 
by  22  well-known  medical  writers/  lM^^'?25  Yq^K,.|jLimp  cloth, 
$125.      Preparing.  ^aT^ETY     LHtTM. -M.        ^^^ 


I 


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